565802454-6-23-2021-29-AS-AASO-C48TV5-20210622150323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802454
Report Date: 06/22/2021
Date Signed: 06/23/2021 08:51:07 AM

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, THE		FACILITY NUMBER:	565802454
ADMINISTRATOR:	BOGOYEVAC, LEATRICE		FACILITY TYPE:	740
ADDRESS:	5300 E LOS ANGELES AVENUE		TELEPHONE:	(805) 583-3500
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	175	CENSUS: 74	DATE:	06/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:27 AM
MET WITH:	Leatrice Bogoyevac		TIME COMPLETED:	02:05 PM

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Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 11:27AM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Lea Bogoyevac and discussed the reason for the visit. Entrance interview conducted.

The LPA along with Administrator Lea toured the physical plant areas inside and outside at 11:40AM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. LPA observed the required postings in the common hallway. Laundry area contains a locked storage cabinet for laundry supplies. The medication room was locked and contained at least 30 day supply of medication. Fire extinguishers were observed to be serviced within the last year. Administrator provided a copy of the Fire Alarm Inspection Report dated 9/10/2020 which indicates that the smoke detectors and pull stations were inspected and tested by Johnson Controls.

The backyard has a covered outdoor area equipped with furniture for resident use. There were bodies of water noted.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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: FOOTHILLS AT SIMI VALLEY, THE	FACILITY NUMBER: 565802454
	VISIT DATE: 06/22/2021

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BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are are a total of 146 bedrooms.

RESTROOMS: Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in restrooms, as well as hand washing posters.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices during the tour. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The facility is allowing visitors, with use of both indoor and outdoor spacing. LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

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