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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850067
Report Date: 09/01/2022
Date Signed: 09/02/2022 08:16:11 AM

Document Has Been Signed on 09/02/2022 08:16 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:VISTA AT SIMI VALLEYFACILITY NUMBER:
565850067
ADMINISTRATOR:CAROL ANN LEROSEFACILITY TYPE:
740
ADDRESS:1236 ERRINGER ROADTELEPHONE:
(805) 351-8802
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 130CENSUS: 65DATE:
09/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Chad BoeddekerTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit regarding an incident which took place on 07/28/2022. LPA met with Executive Director Chad Boeddeker and explained the reason for the visit.

LPA conducted interviews with Executive Director and staff at approximately 3:45 p.m. and reviewed records at approximately 4:00 p.m.

Further investigation is required prior to issuing findings.

Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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