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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850067
Report Date: 11/05/2021
Date Signed: 11/08/2021 12:51:16 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 VALLEYFACILITY NUMBER:
565850067
ADMINISTRATOR:CAROL ANN LEROSEFACILITY TYPE:
740
ADDRESS:1236 ERRINGER ROADTELEPHONE:
(805) 351-8802
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:130CENSUS: 55DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Carol Ann LeRoseTIME COMPLETED:
04:13 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required -1 Year inspection. LPA met with Executive Director Carol Ann LeRose and explained the reason for the visit.

Today's evaluation included but was not limited to: building and grounds, residents' rooms, bathrooms, hot water temperature (read at 112.5-113.9 degrees Fahrenheit) in bathrooms, common areas (dining rooms, library, activity rooms), kitchen, food and first aid supplies. LPA observed sufficient emergency food and water supply. LPA observed sufficient lighting and furnishings in each room. Linens and rooms were clean. LPA observed fire extinguishers fully charged and the last facility fire inspection by Ventura County Fire Department was on 10/07/2021. Centrally stored medicines are kept in a locked medication room. Grab bars and non-skid materials were present in the bathrooms. LPA observed facility to be a comfortable temperature throughout the visit. Indoor and outdoor areas and passageways were free from obstructions. LPA reviewed resident records and medications. LPA reviewed staff records. During facility tour, LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed.

There were no deficiencies observed during LPA's inspection.

Exit interview was conducted with Executive Director Carol Ann LeRose. Today's report was emailed to the Executive Director at clerose@northstarsl.com.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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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