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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850067
Report Date: 11/22/2023
Date Signed: 11/22/2023 05:33:34 PM


Document Has Been Signed on 11/22/2023 05:33 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:VISTA AT SIMI VALLEYFACILITY NUMBER:
565850067
ADMINISTRATOR:VIVAR, BRIMENFACILITY TYPE:
740
ADDRESS:1236 ERRINGER ROADTELEPHONE:
(805) 351-8802
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:130CENSUS: 91DATE:
11/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Madison Lewis, Managing DirectorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian conduct a Required Annual visit to this facility. Upon arrival LPA met with Madison Lewis. LPA was informed that the Executive Director was not in today.

Reason for the visit was stated. Entrance interview was conducted with Ms. Lewis and the inspection process was explained. Copy of the entrance checklist was reviewed and provided to Ms. Lewis to assist with the inspection process. Ms. Lewis confirmed that the facility plan of operation has not changed since licensure. Ms. Lewis was informed that, prior to any changes to the facility or facility plan of operation the licensee needs prior approval for Community Care Licensing. Between 11am-3pm, the LPA and staff Precious Gardner toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers were last inspected on 08/01/2023. The carbon monoxide, smoke alarms and fire suppression system were last tested 09/29/2023 by the Venture County Fire Department and all functioned properly. BEDROOMS and RESTROOMS: The LPA observed total of ten (10) randomly chosen rooms in both assisted living and memory care. Rooms were appropriately furnished, clean and had sufficient lighting. Restrooms inside the randomly chosen rooms were clean and sanitary and in operating condition. The hot water temperature ranged from 113*F to 116*F. Room 221 thermostat was observed not functioning properly during room inspection however the room temperature was within required range (81*F) and comfortable. During the tour LPA also conducted interview with staff and residents who were able to communicate. COMMON SPACES: The lobby, activity rooms, dining rooms, lounge areas, theater, gym, and hair salon were all appropriately furnished and in good condition. The LPA observed the required postings throughout the facility. The patio areas in both memory care and assisted living were equipped with furniture for residents' use. KITCHEN: The commercial kitchen was toured and observed to be clean and appliances all appeared operable. The facility perishable and non-perishable and food supply was observed to be sufficient during todays visit.

Due to time constraints it is determined that the annual inspection will continue on a later date.


Exit interview conducted. Copy of the report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
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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