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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801684
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:09:16 PM

Document Has Been Signed on 08/01/2024 02:09 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:SVS-SIMI VALLEYFACILITY NUMBER:
565801684
ADMINISTRATOR/
DIRECTOR:
LAURA WOODFACILITY TYPE:
775
ADDRESS:2381 TAPO STREET, UNIT DTELEPHONE:
(805) 582-1752
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 60CENSUS: 43DATE:
08/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Laura WoodTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Incident visit at 1:00 p.m. for the purpose of investigating self-reported incident reports. Upon arrival, LPA met with Program Director Laura Wood and explained the reason for the visit.

On 07/24/2024, the Department received a incident reports stating on the morning of 07/19/2024, Staff #1 (S1) was driving around in a circular motion on a cul-de-sac "making donuts" while waiting for a client to come out of their home. Later that day S1 went to a Clients home after S1's shift was completed.

At approx 1pm, LPA conducted physical plant interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. At approx 1:30pm, clients were gathering at the entrance to board facility vehicles to return home. LPA has determined further investigation is needed and will return at a later date to continue.

Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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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