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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801904
Report Date: 12/22/2023
Date Signed: 12/22/2023 04:32:51 PM


Document Has Been Signed on 12/22/2023 04:32 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:BREEN RESIDENTIAL CAREFACILITY NUMBER:
565801904
ADMINISTRATOR:EDWARD M. BREENFACILITY TYPE:
740
ADDRESS:1168 ARCANE STREETTELEPHONE:
(805) 579-7933
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 3DATE:
12/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Calixtro Alex CalixtroTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a Required 1-year to this facility today and met with staff Calixtro Alex Calixtro. Reason for visit was explained. Staff contacted licensee Edward Breen.

A tour of the physical plant was conducted with staff approximately 3:15pm. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete.

Facility has two full bathrooms for resident use. There is a sufficient supply of linens, and towels and toiletries. There are four (4) bedrooms total three (3) are for resident use and one (1) staff room. The facility is maintained at a comfortable (indoor) temperature. Common areas including the living and dining areas were checked for functionality and appear sufficient. Facility has adequate perishable and nonperishable food supplies. LPA observed the backyard has a covered patio area with a table and chairs for resident use. There is a self-latching gate on one side of the facility for resident access. There are no bodies of water or fire arms/ammunition on the premises. Bedrooms observed furnished with all required furniture and had sufficient lighting. Facility has two full bathrooms for resident use. Hot water temperature measured at 110.5 degrees Fahrenheit. There is a sufficient supply of linens, and towels and toiletries. Auditory alarms on all exits were tested and function properly.

LPA tested all carbon monoxide/smoke detectors and found they are all are operable at this time. Fire extinguisher appears to be fully charged on 07/17/2023. There are no issues with Fire Clearance.

Beginning at 3:45PM, LPA reviewed all three (3) resident files. All three (3) client files reviewed contained all required documents. LPA interviewed one client and one staff during todays visit.

Due to time constraints required annual will continue on another day. Staff was informed that a follow up visit will be made to complete the required annual visit. Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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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