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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800884
Report Date: 06/27/2023
Date Signed: 06/29/2023 11:23:36 AM

Document Has Been Signed on 06/29/2023 11:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SIMI OAKS COUNSELING GROUPFACILITY NUMBER:
565800884
ADMINISTRATOR:ERNEST W. FEDERER, PHDFACILITY TYPE:
775
ADDRESS:2345 ERRINGER ST., STE 106TELEPHONE:
(805) 581-4357
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 50CENSUS: 23DATE:
06/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Ernest FedererTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a required annual visit. LPA met with staff and explained the reason for this visit. Administrator Ernest Federer was contacted and arrived shortly after.

LPA and Administrator toured the physical plant area at approximately 12:30pm to ensure compliance.
LPA observed offices and classrooms to have the required furniture and supplies. Medications are stored in a locked cabinet upstairs. Other hazardous/dangerous items are secured in locked cabinets; complete first aid kit is located in locked medication cabinet on the second floor; and another secured down stairs for use. The hot water temperature is maintained within required range (105*f-120*f). All required postings observed throughout the program (upstairs/downstairs). All trash cans observed had tight fitting lids. Smoke/Carbon Monoxide detectors observed/tested and functioned properly.Fire extinguishers observed serviced 7/15/2022.
The facility operating hours are from 9:00 am to 2:00 pm. All participating clients are required to bring a lunch. Small snacks are provided at the program. The restrooms toured observed to be clean and functional. The activity calendars are updated and followed; disaster drills are conducted regularly and logged. Emergency disaster plan is reviewed annually and logged.

Five (5) resident records reviewed from 1pm-1:45pm: all contained written needs and services appraisals and/or Individualize Program Plan (IPP); physician report, signed admission agreements and personal rights forms. Five staff files reviewed at approximately 2pm-2:30pm: all contained current first aid certifications, health screenings, and proof of current CPI and regular in-service training.

LPA was informed that the transportation vehicles utilized by the facility are in working condition and serviced monthly.

Exit interview conducted, Copy of report provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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