565801871-10-8-2024-29-AS-MARO-D9UUFN-20241008153301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801871
Report Date: 10/08/2024
Date Signed: 10/08/2024 03:33:11 PM

Document Has Been Signed on 10/08/2024 03:33 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:	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: 5	DATE:	10/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lidia Medina		TIME COMPLETED:	03:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there were two (2) staff and five (5) residents present. The LPA was greeted by facility staff who contacted the Administrator via telephone. The Administrator, Lidia Medina arrived at 11:30am. Entrance interview conducted.

At 11:38am, the LPA along with the Administrator 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. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 11:38am. Knives and sharps were observed in a locked cabinet inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food; properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: This includes the living room and dining room area. The common areas were furnished appropriately and appeared to be in good condition at the time of the visit. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. Activities for resident use were observed in the living room. LPA observed auditory alarms at the time of the visit. There is a working telephone on premises. LPA observed fireplace adequately covered during the inspection.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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: SIMI HILLS HOME CARE CENTER, LLC	FACILITY NUMBER: 565801871
	VISIT DATE: 10/08/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in both bathrooms, and they measured between 105 and 120 degrees Fahrenheit.

BEDROOMS: There are four (4) bedrooms for resident use; two (2) bedrooms are designated as single occupancy; and two (2) bedrooms are designated as double occupancy. All resident rooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens, towels, and washcloths were observed accessible to residents in care. Staff bedroom observed on premises.

GARAGE: The garage is maintained inaccessible to residents in care. LPA observed an additional refrigerator with food in good condition. There is a washer and dryer inside the garage. Cleaning supplies, detergents, and toxins were observed inaccessible to residents in care. Facility has an adequate amount of emergency food and water.

BACKYARD: The backyard has a covered patio area with adequate furniture for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

RECORDS: LPA reviewed Resident Records at 11:54am and Personnel Records at 12:40pm.

Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were complete.

Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid / CPR training, and the appropriate training. All files were complete.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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: SIMI HILLS HOME CARE CENTER, LLC	FACILITY NUMBER: 565801871
	VISIT DATE: 10/08/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Report Continued from LIC 809C...

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, 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. The smoke detectors and carbon monoxide detector were tested and operational at the time of the visit. Fire extinguisher was observed fully charged with a date of 8/09/2024. Emergency disaster drills conducted quarterly as per regulation; the last drill was conducted on 08/27/2024.

MEDICATIONS: Medications review began at approximately 1:20pm. Medications are stored in a locked cabinet by the kitchen inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3