565801056-9-12-2024-29-AS-MARO-D92SS7-20240912140729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801056
Report Date: 09/12/2024
Date Signed: 09/12/2024 02:07:45 PM

Document Has Been Signed on 09/12/2024 02:07 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:	MILLENNIUM CARE II		FACILITY NUMBER:	565801056
ADMINISTRATOR:	IRIS VAN KRALINGEN		FACILITY TYPE:	740
ADDRESS:	5694 FEARING STREET		TELEPHONE:	(805) 527-7798
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 6	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Iris Van Kralingen		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there were two (2) staff and six (6) residents present. LPA was greeted at the door by Administrator, Iris Van Kralingen and at this time, the reason for the visit was explained. Entrance interview conducted.

At 9:54am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 9:55am. Knives and sharps were observed in a locked drawer inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food; properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: This includes the living room and dining room area. The common areas were furnished appropriately, and all furniture was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. Activities were observed in the living room. There is a working telephone on premises. LPA observed functioning auditory alarms at the time of the visit. No obstructions or hazards were observed inside or out.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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: MILLENNIUM CARE II	FACILITY NUMBER: 565801056
	VISIT DATE: 09/12/2024

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Report Continued from LIC 809...

RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Proper hand washing signs were observed inside the bathrooms. Starting at 10:05am, the hot water temperature was measured; the first bathroom measured at 111.3 degrees Fahrenheit; and the second bathroom measured at 108.1 degrees Fahrenheit.

BEDROOMS: There are three (3) bedrooms for resident use all of which are designated as double occupancy rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Additional clean linens, towels, and washcloths were observed in the hallway closet. There is one (1) staff room on premises.

GARAGE: The garage is maintained locked and inaccessible to residents in care. Laundry room was observed locked at the time of the visit. Cleaning supplies, detergents, and toxins were observed in a locked cabinet inaccessible to residents in care. Facility has an adequate amount of emergency food and water.

BACKYARD: The backyard has a covered patio area with furniture including a table and chairs for resident use. The property is completely fenced with a self-latching mechanism. There is a completely fenced swimming pool, which is kept locked and inaccessible to residents. The exterior passageways were clean and clear of any obstructions at the time of the visit.

RECORDS: LPA reviewed Resident Records at 10:23am and Personnel Records at 11:16am.

Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were complete.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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: MILLENNIUM CARE II	FACILITY NUMBER: 565801056
	VISIT DATE: 09/12/2024

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Report Continued from LIC 809C...

Three (3) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid / CPR training, and the appropriate yearly training. All records were in order.

During today’s visit, the LPA conducted interviews with two (2) staff.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced 06/15/2024. At 10:15am, the smoke detectors and carbon monoxide detector were tested and operational at the time of the visit. Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 08/30/2024.

MEDICATIONS: Medications review began at approximately 12:20pm. The medications are locked in a cabinet adjacent to the living room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications appeared to be given as prescribed at the time of the visit.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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