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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800984
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:18:30 PM

Document Has Been Signed on 08/15/2024 02:18 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 HOMEFACILITY NUMBER:
565800984
ADMINISTRATOR/
DIRECTOR:		LORRAINE MEDINAFACILITY TYPE:
735
ADDRESS:2445 EAST PHYLLIS STREETTELEPHONE:
(805) 581-0751
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 4DATE:
08/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Lorraine MedinaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240705161544). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation.

During the visit on 07/09/2024, LPA observed a menu posted on the refrigerator dated, “third week of December”; however, no recent menu was provided during the visit and facility does not maintain copies of previously used/posted menus. Furthermore, LPA observed the kitchen refrigerator to have food spilled on the shelves. Other food items and drawers were placed on top of the spilled food without cleaning the spilled food.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/15/2024 02:18 PM - It Cannot Be Edited


Created By: Brian Balisi On 08/15/2024 at 12:26 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: PHYLLIS FAMILY HOME
FACILITY NUMBER: 565800984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
85076(d)(4)

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85076(d)(4) Freezers and refrigerators shall be kept clean… This requirement is not met as evidenced by:
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The Administrator will have refrigerator/freezer cleaned out. The Administrator will send photos to CCL on or before POC due date.
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Based on LPA observation, the licensee did not comply with the section cited above, as food spilled on the refrigerator shelves and was not cleaned, but other food and drawers were placed on top of the spilled food, which poses a potential health and safety risk to persons in care.
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Type B
08/23/2024
Section Cited
CCR80076(a)(5)

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80076(a)(5) Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days.

This requirement is not met as evidenced by:
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The Administrator has agreed to prepare and submit next week’s menu to CCL on or before the POC due date.
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Based on record review and observation, the licensee did not comply with the section cited above, as the menu posted was dated in December and it does not accurately reflect food currently served, which poses a potential health and safety or personal rights risk to persons in care
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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:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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