565801291-9-21-2023-29-AS-MARO-CVW2MY-20230921173155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801291
Report Date: 09/21/2023
Date Signed: 09/21/2023 05:32:00 PM

Document Has Been Signed on 09/21/2023 05:32 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:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Venis Caccam		TIME COMPLETED:	05:40 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 1:20 p.m. The last annual conducted at this facility was on 08/29/2022. When the LPA arrived, there were two staff and two residents present. The LPA was greeted at the door by staff, and the Administrator Venis Caccam arrived at 1:50 p.m., at this time the reason for the visit was explained. Entrance interview conducted.

At 1:53 p.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 2:05 p.m. Knives and sharps are locked under the kitchen sink. Cleaning supplies were also observed under the kitchen sink locked and inaccessible to residents in care. Kitchen appliances appeared clean and were in operable condition at the time of the visit. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The facility has a sufficient supply of perishable and non-perishable food. At 2:14 p.m., the hot water temperature was measured at 108.5 degrees Fahrenheit.

Common areas: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 2:06 p.m., the smoke detector(s) and carbon monoxide detector were tested and functioned properly at the time of the visit. The fire extinguisher was observed to be fully charged and serviced on 04/27/2023. There is a functioning telephone on the premises. The LPA observed required postings throughout the common space. At 3:30 p.m., the LPA observed two residents arriving from their day program.

(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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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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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: 09/21/2023

NARRATIVE

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(Report Continued from LIC 809...)

Garage/Outdoor: The washer and dryer are in the garage. Cleaning supplies and toxins were observed locked in a cabinet inside the garage. LPA observed a sufficient supply of emergency food and water. At least a 30-day supply of Personal Protection Equipment (PPE) observed stored in garage. The backyard has a covered outdoor area equipped with chairs and tables for resident use. The LPA observed two side gates that are self-closing and latched. Passageways were observed free of obstructions. No bodies of water noted at the time of the visit.

Restrooms: There are two (2) resident restrooms that were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The LPA observed appropriate hand-washing signs throughout. The hot water temperature was measured in both bathrooms; the first bathroom measured 110.8 degrees Fahrenheit at 1:57 p.m.; and the second bathroom measured 111.2 degrees Fahrenheit at 2:03 p.m.

Bedrooms: The LPA observed the resident bedroom. There are four (4) single occupancy resident bedrooms, which were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed. The LPA observed two staff bedrooms. There was a linen cabinet in the hallway with extra towels and linens.

Records: The LPA reviewed resident records at 2:36 p.m. and staff records at 3:40 p.m. The LPA reviewed four (4) resident files 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. All client files were in order.

The LPA reviewed two (2) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, yearly training, and current first aid certification. All files were complete.

The LPA also audited the current Administrator’s file, and it was in order.

(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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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: 09/21/2023

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(Report Continued from LIC 809C...)

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 3 – Home. The last disaster drill was conducted on 09/18/2023.

At the time of the visit, the LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the liability insurance.

The LPA conducted interviews with two staff members between 4:05 p.m. and 4:13 p.m.

Medications: Medications review began at 4:18 p.m.; medications are centrally stored and locked in a cabinet adjacent to the dining room. Medications are labeled and checked for expiration dates. No errors observed during the medication review.

No deficiencies were noted at this time. Exit interview conducted. Report was reviewed and a copy was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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