565801291-9-10-2024-29-AS-MARO-D8YSRG-20240910140620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801291
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:06:33 PM

Document Has Been Signed on 09/10/2024 02:06 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:	CACCAM'S STANTON RESIDENCE		FACILITY NUMBER:	565801291
ADMINISTRATOR:	VENIS A CACCAM		FACILITY TYPE:	740
ADDRESS:	3726 STANTON COURT		TELEPHONE:	(805) 582-0504
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	4	CENSUS: 4	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Venis Caccam		TIME COMPLETED:	02:15 PM

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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 present. The four (4) clients were in day program at the time of the inspection. LPA was greeted by facility staff who contacted the Administrator via telephone. The Administrator, Venis Caccam arrived at 10:00am. Entrance interview conducted.

At 10:05am, 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 10:15am. Knives and sharps were observed locked and inaccessible under the kitchen sink. 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; labels had dates clearly marked.

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. There is a cabinet adjacent to the living room with resident’s personal hygiene items locked at the time of the visit. Activities were observed in the living room. LPA observed auditory alarms at the time of the visit. There is a working telephone on premises. 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: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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: CACCAM'S STANTON RESIDENCE	FACILITY NUMBER: 565801291
	VISIT DATE: 09/10/2024

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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. Hand washing signs were observed posted inside the bathrooms. The hot water temperature was measured; the first bathroom measured at 116.2 degrees Fahrenheit at 10:09am; and the second bathroom measured at 115.3 degrees Fahrenheit at 10:13am.

BEDROOMS: There are four (4) bedrooms for resident use all of which are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with a chair, dresser, and a bed with clean linens, appropriate furnishings, and sufficient lighting. Additional clean linens, towels, and washcloths were observed in the hallway closet. There are two (2) staff rooms on premises.

GARAGE: The garage is maintained inaccessible to residents in care. LPA observed an additional refrigerator with food in good condition. There is a washer and dryer inside the garage. 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. LPA observed a thirty (30) day supply of Personal Protection Equipment (PPE).

BACKYARD: The backyard has a covered patio area with furniture including a table and chairs for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit.

RECORDS: LPA reviewed Resident Records at 10:32am and Personnel Records at 11:15am.

Four (4) 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 / individual program 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: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CACCAM'S STANTON RESIDENCE	FACILITY NUMBER: 565801291
	VISIT DATE: 09/10/2024

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Report Continued from LIC 809C...

Four (4) 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.

The Administrator certificate is valid until 01/26/2025.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 3-i home.

During today’s visit, the LPA conducted interviews with two (2) staff and obtained copies of the following documents: LIC 500, LIC 9024, LIC 610E, and limited liability insurance.

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. Fire extinguisher was observed to be fully charged and last serviced 04/27/2024. At 10:06am, 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 08/03/2024.

MEDICATIONS: Medications review began at approximately 12:05pm. The medications are locked in a file cabinet adjacent to the dining 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: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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