565801108-3-23-2022-29-AS-ECAS-CCSQPY-20220323122130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801108
Report Date: 03/23/2022
Date Signed: 03/23/2022 12:22:35 PM

Document Has Been Signed on 03/23/2022 12:22 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 VALLEY RESIDENTIAL CARE VI		FACILITY NUMBER:	565801108
ADMINISTRATOR:	MARIA MENDEZ		FACILITY TYPE:	740
ADDRESS:	1391 MELLOW LANE		TELEPHONE:	(805) 217-5284
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS:	DATE:	03/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maria Mendez		TIME COMPLETED:	12:30 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) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff at 9:30 a.m. and explained the reason for the visit. Administrator Maria Mendez arrived a short time after. The LPA toured the physical plant areas inside and outside, with staff and Administrator Maria Mendez between 9:50 a.m. and 10:30 a.m. to ensure there are no health and safety hazards. BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. There are (6) six bedrooms designated for resident use and (1) one bedroom designated for staff use. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed (1) one bathroom without a non-skid surface in the shower, staff indicated the shower is not used by residents. The LPA advised administrator that all showers should maintain non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. The restroom hot water measured between 112.0 and 132.6 Fahrenheit between 10:08 a.m. and 10:16 a.m. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies were observed to be properly stored and locked at time of visit. The LPA observed and unlocked kitchen drawer containing an accessible kitchen knife and lighter. The LPA advised staff to keep all sharps and lighters locked and inaccessible at all times. Hot water measured 134.6 Fahrenheit at 10:09 a.m. Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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 VALLEY RESIDENTIAL CARE VI	FACILITY NUMBER: 565801108
	VISIT DATE: 03/23/2022

NARRATIVE

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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness, living room and dining room furniture was observed to be in good condition, at the time of the visit. The LPA observed required postings in the hallway. Three (3) fire extinguishers were observed to be fully charged and serviced in 6/2021. The LPA observed a covered fireplace in the living room and one (1) carbon monoxide detector in the facility. Smoke/carbon Monoxide detectors are hardwired and interconnected. The LPA tested the smoke/carbon monoxide detectors at 10:27 a.m.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. An unlocked shed in the backyard was observed and contains gardening supplies and gardening chemicals. The LPA observed an attached garage containing a laundry room and office. Laundry supplies were locked at the time of the visit. Office was not in use at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The Administrator was advised that they need to ensure that visitors upon entry are signing in at a central entry point for symptom screening, temperature checks, and sanitation. In addition the LPA advised that Administrator that staff are to continue wearing face masks at all times. The LPA observed 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 COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

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 conducted. A copy of the report and appeal rights were provided via Email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 03/23/2022 12:22 PM - It Cannot Be Edited

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 VALLEY RESIDENTIAL CARE VI	FACILITY NUMBER: 565801108
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in as two (2) out of three (3) bathroom water temperatures measured at 132.6 degrees Farenheit and the kitchen sink measured at 134.6 degrees Farenheit which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/23/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Adjust the water temeperature to meet CCL regulations. Plan of correction met at time of the visit.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as there was an unlocked kitchen cabinet contianing an accessible kitchen knife and lighter which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/23/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Remove and lock knife and lighter in appropriate storage area. Plan of correction met at time of the visit.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 03/23/2022 12:22 PM - It Cannot Be Edited

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 VALLEY RESIDENTIAL CARE VI	FACILITY NUMBER: 565801108
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the shed in the backyard containing gardening supplies and toxic chemicals was unlocked and accessible which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/23/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Secure storage shed and accesible items. Plan of correction met at time of the visit.

Type A

Section Cited

CCR

87468.1

Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as one (1) staff who was providng care and supervision to residents was observed without a face mask upon arrival, in violation of official government orders requiring the wearing of face coverings while working under specified conditions, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/23/2022
	Plan of Correction
1 2 3 4	The administrator agreed to do the following: 1. Ensure that staff are reminded of the departments masking protocols and mask is kept on at all times. Plan of correction met at the time of the visit.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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