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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802473
Report Date: 07/20/2023
Date Signed: 07/20/2023 05:52:26 PM

Document Has Been Signed on 07/20/2023 05:52 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:BCBN LLCFACILITY NUMBER:
565802473
ADMINISTRATOR:FARRUGGIA, FABIANAFACILITY TYPE:
735
ADDRESS:55 VISTA LAGO DRTELEPHONE:
(805) 422-8122
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 3DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jacqueline Contreras, StaffTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Zabel Chochian conduct a required annual to this facility today. Upon arrival LPA met with staff Jacqueline Contreras and explained the reason for the visit. Staff contacted administrator .

From 11am - 11:30am, the LPA and staff toured the physical plant areas inside and outside to ensure the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly.

KITCHEN: Knives and medications are stored in locked drawers. Cleaning supplies are stored in a locked closet in the hall. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed one shared client bedroom and two single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restroom for clients was clean and sanitary and in operating condition. COMMON SPACES: Living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the entryway. FRONT/BACKYARD: Front/backyard observed clear of any safety hazards. The backyard patio is equipped with furniture for clients' use.

CLIENT/STAFF: Files reviewed from 11:30am-12pm. Client files observed complete with all required records. Staff files reviewed also observed complete with all required records and training.



MEDICATIONS: Reviewed from 12-12:30pm. Proper storage and medication documentation on file; No discrepancies observed.

No deficiencies observed. Exit interview conducted, copy of report provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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