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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802454
Report Date: 07/20/2022
Date Signed: 07/21/2022 10:47:06 AM


Document Has Been Signed on 07/21/2022 10:47 AM - 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: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: 87DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Vanathda Dunn - Memory Care DirectorTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Zabel Chochian conducted an unannounced Required Annual inspection. This annual had a specific emphasis on infection control practices and procedures. The LPA met with designated staff and reason for visit was explained. LPA and staff toured the physical plant areas to ensure the facility is in compliance with Title 22 Regulations.

INFECTION CONTROL: During today’s visit, LPA spoke with the staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection 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.

Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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