565801871-9-9-2021-29-AS-MGCZ-C6PQRW-20210909122438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801871
Report Date: 09/09/2021
Date Signed: 09/09/2021 12:25:21 PM

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:	SIMI HILLS HOME CARE CENTER, LLC		FACILITY NUMBER:	565801871
ADMINISTRATOR:	LIDIA MEDINA		FACILITY TYPE:	740
ADDRESS:	2062 VERA COURT		TELEPHONE:	(818) 577-8231
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 2	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lidia Medina		TIME COMPLETED:	12:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced visit to Simi Hills Home Care Center, LLC to conduct a Required 1-Year Annual Inspection with focus on Infection Control. Last annual conducted was on 8-18-2019. LPA was greeted and screened at the door by staff Antonio Salazar. Administrator Lidia Medina and Angelica Medina arrived at the facility shortly after and were explained the reason for the visit. Entrance interview conducted.

LPA 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. LPA along with Administrator Lidia, initiated a tour at 9:38am and the following was observed:

There is a central entry point designated for universal screening for visitors by the entrance. At 10:27 am, Smoke detectors and Carbon Monoxide detector were tested and functioned properly. Fire extinguisher was observed to be fully charged on June 12, 2021. First-Aid Kit was observed to be complete. Medications are in the kitchen in a locked cabinet. Main temperature displayed by hallway and read at 74 degrees Fahrenheit for the facility. LPA conducted a file review for two (2) residents at facility. All required forms and pertinent documents were observed to be completed.

OUTDOOR SPACE: LPA observed the backyard to have a covered outdoor area with a tables and chairs for resident use. There is one (1) gate on the side of the house that has a single latch and remains unlocked.

KITCHEN: LPA observed the kitchen/dining area to be clean. Knives are stored in a locked cabinet under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

-Continued on LIC 809c

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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: SIMI HILLS HOME CARE CENTER, LLC	FACILITY NUMBER: 565801871
	VISIT DATE: 09/09/2021

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Continued from LIC 809

BEDROOMS: LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and adequate lighting.

RESTROOMS: LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. LPA observed signs posted in resident bathrooms and kitchen sink on washing hands and cough etiquette. Water temperature was checked in two (2) resident bathrooms and are in compliance at 105.8 degrees Fahrenheit for bathroom #1- and 106 degrees Fahrenheit for bathroom #2.

LPA observed at least a 30-day supply of Personal Protection Equipment (PPE). The facility cleans the common areas at least twice daily. There are signs posted throughout the facility showing cough/sneeze etiquette and how to properly wash hands. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

During plant tour, Administrator printed and posted CDSS PINs in an easily accessible area for both residents and visitors.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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