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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801684
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:44:36 PM

Document Has Been Signed on 11/14/2024 01:44 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: 44DATE:
11/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Laura WoodTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Incident visit for the purpose of investigating a self-reported incident report and SOC 341. LPA met Program Director, Laura Wood and explained the reason for the visit. Entrance interview conducted.

On 11/06/2024, the Department received an incident report stating that on 11/05/2024 at approximately 3:30 p.m., a staff shared in a meeting with Regional Director and Case Manager that they had overheard Staff #1 (S1) have an inappropriate sexual conversation with Participant #1 (P1) several times. Staff stated that the joking was inappropriate. The comment made by S1 was using a partial gesture with their pinky raised indicating the size of P1’s private part. S1 was suspended on the morning of 11/06/2024 pending further investigation.

During today’s visit, the LPA conducted a plant tour at approximately 10:00 a.m., conducted interviews with five (5) staff and two (2) clients between 9:40 a.m. and 12:15 p.m., conducted a file review at 10:15 a.m., and obtained copies of pertinent documents.

Interviews conducted with the Program Director revealed that S1 is no longer suspended as they have been terminated from their position as of 11/08/2024. Interviews conducted with participants revealed that S1 along with another staff had made inappropriate comments and or statements making the participants feel uncomfortable. Based on the investigation's findings, there is sufficient evidence to conclude that S1 made inappropriate comments and or statements to P1.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D).



Exit interview conducted. Copy of report and appeal rights were reviewed and provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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Document Has Been Signed on 11/14/2024 01:44 PM - It Cannot Be Edited


Created By: Martha Arroyo On 11/14/2024 at 01:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SVS-SIMI VALLEY
FACILITY NUMBER: 565801684

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
82072(a)(1)

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(a) Each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by:
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The Licensee has agreed to hold a staff training on participants personal rights and send proof of training with staff signatures to CCL no later than POC due date.
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Based on the information obtained thorugh interviews, the Licensee did not comply with the section cited above as S1 made inappropriate comments/statements to P1 making them uncomfortable, which poses an immediate personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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