565850067-11-10-2022-29-AS-TCAA-CL2RYL-20221110122630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850067
Report Date: 11/10/2022
Date Signed: 11/10/2022 12:29:11 PM

Document Has Been Signed on 11/10/2022 12:29 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 VALLEY		FACILITY NUMBER:	565850067
ADMINISTRATOR:	CAROL ANN LEROSE		FACILITY TYPE:	740
ADDRESS:	1236 ERRINGER ROAD		TELEPHONE:	(805) 351-8802
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	130	CENSUS: 59	DATE:	11/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Manuel Hernandez		TIME COMPLETED:	12:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 9:37 a.m.. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Resident Care Director Manuel Hernandez, LVN as the acting Executive Director Doug Rice was not in today. LPA explained the reason for the visit.

The LPA 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 8/10/2022. The carbon monoxide, smoke alarms and fire suppression system were last tested 6/3/2022 by the Ventura County Fire Department and all functioned properly.

KITCHEN: The commercial kitchen was clean and appliances all appeared operable. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The LPA observed ten randomly chosen rooms in both assisted living and memory care. Rooms were appropriately furnished, clean and had sufficient lighting. The hot water temperature ranged from 109*F to 114.5*F. LPA observed Tylenol stored in an open cabinet in the kitchenette in room 123.

RESTROOMS: Restrooms inside the randomly chosen rooms were clean and sanitary and in operating condition. LPA observed Aspirin in room 127 in an open medicine cabinet and Febreeze room deodorizer in room 104 in the memory care unit stored in an open drawer.

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.

(continued on 809-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

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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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: 11/10/2022

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(continued from 809)

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Today's reports and appeal rights were discussed. A copy of the report was emailed to the Administrator and Resident Care Director.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/10/2022 12:29 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in three out of ten resident rooms LPA observed over-the-counter medication in two rooms and room deodorizer in one room that were in unlocked cabinets, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2022
	Plan of Correction
1 2 3 4	The Resident Care Director will train caregivers and medication technicians regarding safe storage of medications and other toxic substances and will provide evidence of this training to CCL on or before 11/18/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC809 (FAS) - (06/04)

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