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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801108
Report Date: 02/28/2023
Date Signed: 03/13/2023 11:17:33 AM


Document Has Been Signed on 03/13/2023 11:17 AM - 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 VIFACILITY NUMBER:
565801108
ADMINISTRATOR:MARIA MENDEZFACILITY TYPE:
740
ADDRESS:1391 MELLOW LANETELEPHONE:
(805) 217-5284
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:44 PM
MET WITH:Maria MendezTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at this facility to conduct a required annual visit. LPA met with Administrator Maria Mendez and staff. This annual had a specific emphasis on infection control practices and procedures. LPA spoke with the Administrator regarding the facility’s infection control practices.

Physical plant tour was conducted with staff at approximately 4:50pm. The LPA observed the required postings throughout the facility. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The LPA observed an adequate supply of surgical masks and gloves however LPA did not observe a 30 day supply of Personal Protection Equipment (PPE). Administrator stated they will prepare and maintain a 30 day PPE supply at the facility following this visit. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged with last service date 07/18/2022.

KITCHEN: Knives were stored in a locked drawer and cleaning supplies were stored in the locked cabinet under the sink and garage. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean and sanitary and in operating condition. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The backyard observed hazard free during todays visit.

No deficiencies observed. Exit interview conducted. Report emailed to Administrator.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
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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