565800884-5-23-2024-29-AS-MARO-D5JSEK-20240523134852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800884
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:49:30 PM

Document Has Been Signed on 05/23/2024 01:49 PM - 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 GROUP		FACILITY NUMBER:	565800884
ADMINISTRATOR/ DIRECTOR:	ERNEST W. FEDERER, PHD		FACILITY TYPE:	775
ADDRESS:	2345 ERRINGER ST., STE 106		TELEPHONE:	(805) 581-4357
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 50		CENSUS: 25	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Ernest Federer		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced required annual today. The last annual conducted at this location was on 06/27/2023. Upon arrival LPA met with the Administrator, Ernest Federer and explained the reason for the visit. Entrance interview conducted. At 9:23 a.m. the LPA along with the Administrator toured the physical plant areas to ensure that there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. There are twenty-two (22) staff and twenty-five (25) clients present at the day program today. The day program operates from 9:00 a.m. to 2:00 p.m. The day program is currently staffed appropriately with the necessary staff to client ratios. The day program consist of two (2) floors with seventeen (17) activity rooms. The facility has one kitchenette for staff use. Refrigerator contains staff's lunch, snacks, and drinks. Clients are required to provide their own lunch. Activity rooms and office furniture were observed to be in good condition at the time of the visit. LPA observed hazardous/dangerous items secured in locked cabinets. Cleaning supplies were also observed locked and inaccessible at the time of the visit. The smoke detectors and carbon monoxide detector were tested and operational at the time of the visit. LPA observed the required postings throughout the facility. Fire extinguishers were observed to be fully charged and last serviced on 07/15/2023. Facility temperature is kept at a comfortable temperature. No bodies of water noted at the time of the visit. Activities are both designed for both as individuals and as a group. The LPA observed staff interacting with clients during time of visit. No obstructions or hazards were observed inside or out. Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 GROUP	FACILITY NUMBER: 565800884
	VISIT DATE: 05/23/2024

NARRATIVE

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Continued from LIC 809...

Records review began at approximately 9:57 a.m. Four (4) client records were reviewed for the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, Individual Program Plans (IPP), and current needs and services plan. All client records were in order.

Four (4) staff files including the Administrator’s file were reviewed for, but not limited to the following: personnel records, health screening, criminal record statements, and valid first aid/CPR. All staff records were in order.

Last emergency disaster plan was updated on January 2024 and last emergency disaster drill was conducted on 01/05/2024. LPA was informed that the transportation vehicles utilized by the facility are in working condition and serviced monthly.

At 12:15 p.m., records reviewed revealed that Staff #1 (S1) was hired on 11/21/2022 and was observed working at the facility at the time of the inspection. However, on 09/14/2023, the Department mailed out an Exemption Denial for S1 stating that S1 may not work or be present in an agency licensed by the Department. The Administrator had S1 removed from the premises at the time of the visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 the following deficiencies were observed and cited. Refer to the following LIC 809-D pages for list of deficiencies. Civil penalty issued in the amount of $500. Failure to correct deficiencies may result in additional civil penalties.

Exit interview conducted with the Administrator. A copy of the report and Appeal Rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 01:49 PM - It Cannot Be Edited

Created By: Martha Arroyo On 05/23/2024 at 01:23 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMI OAKS COUNSELING GROUP	FACILITY NUMBER: 565800884
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

82019(e)(1)

(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above as S1 has an exemption denial; however, has continued working at the day program, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	The Licensee had S1 removed from the premises at the time of the visit. The Licensee will disassociate and remove S1 from the facility roster and send proof to CCL by poc due date. A $500 immediate civil penalty has been assessed today for criminal record clearance.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Desaree Perera

LICENSING EVALUATOR NAME:

Martha Arroyo

LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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