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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801690
Report Date: 11/22/2024
Date Signed: 11/22/2024 11:27:23 AM

Document Has Been Signed on 11/22/2024 11:27 AM - 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:SENIORS WAY INC.FACILITY NUMBER:
565801690
ADMINISTRATOR/
DIRECTOR:		MARGIERY D MENORCAFACILITY TYPE:
740
ADDRESS:4005 SNOWGOOSE STREETTELEPHONE:
(805) 422-8144
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 5TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
11/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Luisito BallesterosTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analysts (LPA)'s Brian Balisi and Zabel Chociah conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20241120152741). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA's met with Margiery D Menorca outside of the facility and explained the reason for the visit. Margiery stated they are unable to stay for the visit, but informed the LPA's that their staff and can sign for the report.

During the Department’s investigation, the following deficiencies were observed:

At approx 10:15 a.m LPA's were not allowed to tour the 2nd floor of the home.
At approx 10:30 a.m. LPA's records review revealed incomplete file for residents in care.
At approx 10:35 a.m. LPA records review of staff files revealed incomplete files for two (2) staff.


Based on the numerous deficiencies noted during the course of the investigation of complaint #29-AS-20241120152741, the administrator did not demonstrate knowledge of the requirements of Title 22 Regulations. L

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Failure to correct the deficiencies may result in civil penalties.
 
Exit interview conducted/ Staff refused to sign/ A copy of report was also provided to the staff.
Desaree PereraTELEPHONE: (818) 596-4347
Brian BalisiTELEPHONE: (818) 421-9171
DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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 11/22/2024 11:27 AM - It Cannot Be Edited

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: SENIORS WAY INC.
FACILITY NUMBER: 565801690

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Any duly authorized officer...secure compliance with, or to prevent a violation of, this chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 11/25/2024
Plan of Correction
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Licensee agreed to review section cited and provide a statement of understanding to LPA via email by COB of due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Desaree PereraTELEPHONE: (818) 596-4347
Brian BalisiTELEPHONE: (818) 421-9171

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/22/2024 11:27 AM - It Cannot Be Edited

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: SENIORS WAY INC.
FACILITY NUMBER: 565801690

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidence by:
Deficient Practice Statement
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POC Due Date: 11/29/2024
Plan of Correction
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Licensee agreed to keep full personnel files. Licensee also agree to review section cited and provide a statement of understanding to LPA via email by COB 11/29/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree PereraTELEPHONE: (818) 596-4347
Brian BalisiTELEPHONE: (818) 421-9171

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

LIC809 (FAS) - (06/04)
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