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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802454
Report Date: 08/07/2020
Date Signed: 08/07/2020 05:09:10 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:FOOTHILLS AT SIMI VALLEY, THEFACILITY NUMBER:
565802454
ADMINISTRATOR:BOGOYEVAC, LEATRICEFACILITY TYPE:
740
ADDRESS:5300 E LOS ANGELES AVENUETELEPHONE:
(805) 583-3500
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:175CENSUS: DATE:
08/07/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Pam MundayTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Aja Richardson conducted an unannounced case management visit to conclude the investigation into two incident reports received in the Woodland Hills Regional Office on 08/05/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with the facility administrator Pam Munday.

According to the incident report on 8/3/2020 at 12 pm Resident #1 (R1) and Resident #2 (R2) from memory care were observed by staff outside of facility. R1 was observed 1/2 mile from the facility and R2 was observed walking to the front entrance. Both residents medications are being reviewed by their primary care doctor and staff has been trained on door alarm protocol and alarm re engagement.

At 3:45, LPA spoke with the Administrator who stated that delay egress doors work however staff were turning down their phones so that they could not hear the alarm. To rectify this situation the staff have been trained to not change the volume on the alerts and they have bought back up alarms to put on doors to alert staff that residents have left.

There were no citations given on this date. Further investigation is needed.

Exit Interview Conducted. Report Issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020
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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