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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802454
Report Date: 05/12/2021
Date Signed: 05/12/2021 10:46:58 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: 68DATE:
05/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:44 PM
MET WITH:Sandra Albarron, Assisted Living DirectorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent Case Management Tele-Inspection regarding a self reported incident. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted telephonically with Ms. Albarron,

LPA initiated a Case Management virtual visit today to gather additional information pertaining to 5/3/2021 incident involving resident #1 and staff #1. Incident was discussed with Ms. Albarron and Ms. Sahar Mosalla the Interim Administrator. LPA requested that the SOC341 be resubmitted with required information and appropriate cross reported boxes checked. In addition, LPA requested that an incident report be filed out and submitted with the SOC341.

LPA attempted to communicate with resident #1 via FaceTime however resident #1 was unable to communicate via FaceTime. Resident was able to communicate telephonically. LPA conducted a telephonic interview with resident #1 at approximately 4:50pm.

Based on the information received today it was determined that further investigation is needed. A telephonic exit interview was conducted with Ms. Albarron and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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