565801108-4-29-2024-29-AS-MARO-D4ST79-20240429142821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801108
Report Date: 04/29/2024
Date Signed: 04/29/2024 02:29:07 PM

Document Has Been Signed on 04/29/2024 02:29 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:	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: 6	DATE:	04/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Maria Mendez		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analysts (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required Annual inspection today. Upon arrival, there were two (2) staff members and six (6) residents present. The LPA was greeted at the door by staff, Nhoel Villanueva and the reason for the visit was explained. The Administrator, Maria Mendez arrived at 9:35 a.m. Entrance interview conducted.

At 9:40 a.m., 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.

KITCHEN: The LPA inspected the kitchen/food service area at 10:00 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and pantry were checked for proper labels and expiration dates. Knives and sharps were observed in a locked drawer inaccessible to residents in care.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 10:05 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational. Fire extinguishers were observed fully charged with a date of 07/12/2023. There is a locked closet in the hallway with personal hygiene items inaccessible to residents in care. The LPA observed required postings throughout the common space. There is a working telephone on premises. Indoor cameras were observed throughout the common areas.

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: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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: SIMI VALLEY RESIDENTIAL CARE VI	FACILITY NUMBER: 565801108
	VISIT DATE: 04/29/2024

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Continued from LIC 809...

GARAGE: The garage connects through the kitchen. The washer and dryer were observed inside the garage. Detergents and cleaning supplies were observed in a locked cabinet inaccessible to residents at the time of the visit. An adequate supply of emergency food and water was observed at the time of the visit.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There are two (2) side gates with closing mechanism. The LPA observed a locked shed with gardening tools inaccessible to residents in care. No bodies of water were noted at the time of the visit.

BEDROOMS: There are six (6) resident bedrooms which are all for single occupancy. LPA observed the resident bedrooms to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. There is a designated staff room on premises.

RESTROOMS: There are three (3) resident restrooms. Restrooms were observed with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Starting at 9:43 a.m.., the hot water temperature was measured in all three (3) bathrooms, and they measured between 108.6- and 112.1-degrees Fahrenheit.

RECORDS: Records review began at 10:15 a.m.; six (6) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. Records were in order.

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. Files were complete.

The last emergency disaster drill was conducted on 04/15/2024.

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: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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: SIMI VALLEY RESIDENTIAL CARE VI	FACILITY NUMBER: 565801108
	VISIT DATE: 04/29/2024

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Continued from LIC 809C...

The LPA obtained copies of the following documents at the time of the inspection: Personnel Report LIC 500, Client Roster LIC 9020, Emergency Disaster Plan LIC 610E, and current Limited Liability Insurance.

MEDICATIONS: Medications review began at approximately 12:20 p.m.; medications are centrally stored in a locked cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record. Medications appeared to be given as prescribed at the time of the visit.

Exit interview conducted. No citations issued. Report was reviewed and a copy was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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