565850067-11-23-2020-29-AS-ASMH-BVMUDC-20201123142918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850067
Report Date: 11/23/2020
Date Signed: 11/23/2020 02:29:46 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:	VISTA AT SIMI VALLEY		FACILITY NUMBER:	565850067
ADMINISTRATOR:	UNKNOWN		FACILITY TYPE:	740
ADDRESS:	1236 ERRIGNER ROAD		TELEPHONE:	(530) 242-8300
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	130	CENSUS: 0	DATE:	11/23/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Carol Ann LeRose		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Smith arrived at the facility at 9am for an announced pre-licensing inspection. Upon arrival, the LPA met with Executive Director Carol Ann LeRose. The applicants successfully completed Component II on 11/16/2020 and Component III on 11/20/2020. A fire clearance was approved on 10/28/2020 and all rooms were cleared for non-ambulatory use. All rooms were cleared for bedridden use; however, this facility shall be limited to a maximum capacity of ten (10) bedridden residents. Entrance interview conducted. COMMON AREAS: The physical plant tour took place at 9:05am. The facility is a two-story building. Facility has 2 working elevators and 3 stairwells. On the first floor, there are the kitchen facilities, dining room, laundry rooms, medication room, conference room/private dining, office rooms. On the second floor, there is a large activity room, movie room, salon, gym, massage room, computer/library space, laundry room, and common restrooms. There is no video surveillance in the common areas at this time. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. The signal system is Code Alert, which is activated via pullcord in resident rooms and common areas. Exits are equipped with a wanderguard system and residents will have the option to use a pendant. System was tested randomly throughout the visit and it was in operating condition. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted throughout the facility. Other required postings will be posted in the hallway. There are fire extinguishers throughout the facility, which were purchased 08/18/2020. The building received a final inspection from the fire department on 10/22/2020 and smoke detectors and carbon monoxide detectors were observed to be in operating condition. The sprinkler system was checked 10/12/2020 and was deemed in operating condition. The LPA obtained documentation regarding the fire inspection for the hard file.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: VISTA AT SIMI VALLEY	FACILITY NUMBER: 565850067
	VISIT DATE: 11/23/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The LPA toured the outside area of the facility. There is parking available for resident use. There are two outdoor gated courtyards: one is designated for Memory Care residents and the other designated for Assisted Living residents. There is a fountain in the Assisted Living outdoor courtyard. There is delayed egress on the exit door of the Memory Care courtyard; it was tested and operational during today’s visit. The exit door of the Assisted Living courtyard is not equipped with delayed egress; however, it is equipped with a Wanderguard to alert the front desk should someone exit. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents at both courtyards. Facility has a passenger bus for resident transportation needs.

MEDICATION: The main medication room is located on the first floor, which will house all the medication for the entire facility. There is a complete first-aid kit and a surplus of medical supplies. There are additional first aid kits throughout the facility. There is a medication cart with a double locking system for narcotics.

KITCHEN: The main kitchen and dining room are located on the 1st floor. Food is prepared in the main kitchen and delivered to the dining area and the Memory Care dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries, and food delivery takes place twice a week.

RESIDENT ROOMS: Memory Care is located on the first floor and has 20 rooms, identified as Rooms 101 – 120. Out of the 20 rooms, 15 rooms are single occupancy and 5 rooms are double occupancy. The Memory Care Unit has all studio apartments with no appliances. All rooms in the Memory Care Unit are complete, with properly installed grab-bars in resident bathrooms and non-skit surfaces in shower tubs. During today's visit, water temperature was tested throughout the rooms and temperature ranged between 106 to 116 degrees Fahrenheit, which is within the required range per regulation of 105 to 120 degrees Fahrenheit. At this time, Rooms 136, 139, and 249 are used for storage.

Assisted Living rooms are identified on the first and second floor. Rooms for Assisted Living residents are both studio and one bedroom, and are equipped with a refrigerator and sink. The LPA identified that the whereas the following bathrooms in the Assisted Living units have grab bars in the shower, the following bathrooms require additional grab bar installation by the toilet: Rooms 133, 135, 140, 202-208, 211-222, 225-228, 231-232, 234-237, 239-246, and Rooms 250-253. The applicant provided documentation to the LPA, demonstrating that the additional grab bars were ordered with an estimated delivery date of 11/23/2020.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: VISTA AT SIMI VALLEY	FACILITY NUMBER: 565850067
	VISIT DATE: 11/23/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Physical plant is in compliance with Title 22 regulations. The applicant understands and agrees that residents may not move into specific rooms (see above) until the appropriate grab bars are installed by the toilet. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3