565800984-1-17-2025-29-AS-BBAI-DCZT7C-20250117132830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800984
Report Date: 01/17/2025
Date Signed: 01/17/2025 01:29:04 PM

Document Has Been Signed on 01/17/2025 01:29 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:	PHYLLIS FAMILY HOME		FACILITY NUMBER:	565800984
ADMINISTRATOR/ DIRECTOR:	LORRAINE MEDINA		FACILITY TYPE:	735
ADDRESS:	2445 EAST PHYLLIS STREET		TELEPHONE:	(805) 581-0751
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 4		CENSUS: 4	DATE:	01/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Lorraine Medina		TIME VISIT/ INSPECTION COMPLETED:	01:45 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) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Licensee Lorraine Membreno arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 10:00 a.m. Knives and sharp objects are stored in a locked drawer to the right of the sink. No cleaning supplies were observed kept in the kitchen. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. LPA observed medication centrally stored and resident files securely stored in this area as well. At the time of the visit, the common area's furniture were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in the hallways cabinets. A sufficient supply of PPE and toiletries were observed stored inaccessible to residents in care in a hallway closet. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last serviced on October 15, 2024. The LPA observed four (4) client bedrooms , which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bathrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with supplies and paper towels. At approx 10:13 a.m. The hot water temperature was measured at 98 degrees Fahrenheit. The Administrator adjusted water heater during the visit and the temperatures in each bathroom measured between 107 - 111 degrees Fahrenheit.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

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: PHYLLIS FAMILY HOME	FACILITY NUMBER: 565800984
	VISIT DATE: 01/17/2025

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There are two (2) rooms designated for staff use. LPA observed (1) room to have staff sleeping and the other room to be empty during the visit. Both rooms were observed to be inaccessible to clients in care. A sufficient supply of PPE was observed in the hallways closet near the stairs.

LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to clients in care. LPA observed garage to store an additional fridge and freezer to store extra perishable food, extra non-perishable food, additional supplies, as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) unobstructed exit passageways during the visit. There is a shed in the rear of the facility. LPA observed it to be inaccessible to clients in care and to store tools, and additional supplies for facility use. There were no bodies of water noted at the time of the visit.

Records review began at approx. 10:30am, four (4) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Three (3) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time .Next emergency disaster drill to be conducted by end of month.

Medications review began at approx. 01:00 p.m. All medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time.

Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.
The LPA obtained the following documents at the time of visit: LIC500 Personnel Report and LIC9020 Client Roster. Interviews were conducted during the visit.
Exit interview conducted, technical violation issued for water temperature and a copy of the report was provided to Licensee

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC809 (FAS) - (06/04)

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