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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801684
Report Date: 12/16/2024
Date Signed: 12/16/2024 01:32:39 PM

Document Has Been Signed on 12/16/2024 01:32 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: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: 42DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Laura Wood - Program DirectorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one year annual inspection today at 9:15AM. The last annual conducted at this facility was on 12/19/2023. Upon arrival, there were thirteen (13) staff, and forty-two (42) participants present at the day program. The LPA met with Program Director, Laura Wood and the reason for the visit was explained. Entrance interview.

At 9:40AM, the LPA along with the Program Director toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted during the plant tour:

The day program operates from 8:00AM to 1:30PM. The drivers will start participant pick-ups at 7:00AM and begin drop-offs at 1:30PM. The day program is currently staffed appropriately with the necessary staff to consumer ratios. The facility has seven (7) activity rooms, four (4) client bathrooms, a staff breakroom, a kitchen area, and staff offices.

KITCHEN: At 9:43AM, the LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The refrigerator was observed with participant’s snacks. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 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: SVS-SIMI VALLEY
FACILITY NUMBER: 565801684
VISIT DATE: 12/16/2024
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Report Continued from LIC 809...

BATHROOMS: There are four (4) bathrooms for participant use. The LPA inspected the bathrooms for cleanliness, restrooms were clean and trash cans have lids to protect participants from cross contamination. The bathrooms were sufficiently stocked with soap and paper towels. Starting at 9:47AM, the hot water temperature was tested and was within the required range as they measured between 109.9 and 116.2 degrees Fahrenheit at the time of the visit.

COMMON AREAS: These include seven (7) activity rooms and kitchen area. The common areas were furnished appropriately, and all furniture was observed to be in good condition at the time of the visit. Equipment used for activities was also in good condition and is being cleaned at least once per day. Facility maintained at a comfortable temperature. Activities are both designed for both as individuals and as a group. The LPA observed staff interacting with participants during the inspection. There were no obstructions and/or tripping hazards observed. The LPA observed storage room with additional activity supplies and cleaning supplies locked and inaccessible to participants at the time of the visit. The LPA observed required postings throughout the common space. No bodies of water noted at the time of the visit.

RECORDS REVIEW: The LPA reviewed participant records at 10:10AM and staff records at 11:12AM.

Five (5) participant files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, needs and service plan and individualized service plan. All participant files were in order.

Five (5) staff files including the current Program Director’s file were reviewed for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification and yearly training. All files were complete.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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: SVS-SIMI VALLEY
FACILITY NUMBER: 565801684
VISIT DATE: 12/16/2024
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Report Continued from LIC 809C...

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, the 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. There are several fire extinguishers throughout the facility; they all were fully charged and were last serviced on 12/12/2024. The last fire safety inspection was completed on 06/08/2023 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; the last drill was conducted 11/15/2024.

MEDICATIONS: Day program does not have centrally stored medications as there are currently no participants requiring routine medications and/or PRNs during the day program at the time of the visit.
Exit interview conducted. No citations issued. Report was reviewed and a copy was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3