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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801291
Report Date: 08/29/2022
Date Signed: 08/30/2022 11:34:43 AM


Document Has Been Signed on 08/30/2022 11:34 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:CACCAM'S STANTON RESIDENCEFACILITY NUMBER:
565801291
ADMINISTRATOR:KIRSTIE CACCAM THOMPSONFACILITY TYPE:
740
ADDRESS:3726 STANTON COURTTELEPHONE:
(805) 582-0504
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 6DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Operator - Venis CaccamTIME COMPLETED:
02:00 PM
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A required annual visit was conducted today, which has an emphasis on infection control practices and procedures. Upon arrival Licensing Program Analyst (LPA) met with staff. Staff contacted Administrator and reason for visit explained was explained.

LPA and Ms. Caccam toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. KITCHEN: Knives and sharp objects are stored in a locked cabinet. Cleaning supplies are stored locked and inaccessible to residents. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Resident bedrooms observed furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms observed clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms were fully stocked with soap and paper towels. Appropriate hand-washing signs observed in the bathroom. COMMON SPACES: COVID-19 signage observed that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. At the time of the visit, living room and dining room furniture observed to be in good condition. LPA observed the required licensing postings listed throughout the facility. The backyard has a covered outdoor patio, observed hazard free. There were no bodies of water noted. At least 30 day supply of Personal Protection Equipment (PPE) observed stored in garage.

INFECTION CONTROL: Today, the LPA spoke with Operator - Venis Caccam regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The 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. This facility has records of staff and resident vaccinations. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The facility’s policies and procedures pertaining to infection control are in place.

Exit interview conducted. Email Administrator copy of today's report.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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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