565850067-2-28-2023-29-AS-DPEA-CPH3FF-20230228171241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850067
Report Date: 02/16/2023
Date Signed: 02/28/2023 04:34:01 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2023 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20230207101044

FACILITY NAME:	VISTA AT SIMI VALLEY		FACILITY NUMBER:	565850067
ADMINISTRATOR:	RICE, DOUGLAS		FACILITY TYPE:	740
ADDRESS:	1236 ERRINGER ROAD		TELEPHONE:	(805) 351-8802
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	130	CENSUS: 69	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Dan Zaharoni, Licensee & Brimen Vivar, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff do not respond to resident's call button in a timely manner
Facility is not maintained at a comfortable temperature for resident

INVESTIGATION FINDINGS:

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**This report is amended to correct a technical error. Licensing Program Analyst (LPA) Zabel Chochian conducted a complaint visit to the facility. LPA met with licensee Dan Zaharoni and explained the reason for the visit. Discussion held with Mr. Zaharoni regarding allegations above from approximately 9:45am-10:15am. During today's visit LPA conducted a physical plant tour and conducted random resident interviews from approximately 10:30am-12:00pm and 2:30pm-3pm; Staff interviews conducted from 12:15pm-1:45pm; Review of the pager response time record for 7 days conducted from 1:45pm-2:30p. Based on interviews conducted and a review of the pager response times, it was confirmed that, in several instances, staff response times are taking over ten (10) minutes to one (1) hour. Regarding the facility maintaining a comfortable temerature for residents, it was confirmed through resident interviews that the facility common areas and resident rooms have been cold. Licensee confirmed that the facility is expirence issues with the heating/cooling system. LPA observed room tempetures to range from 58-69 degrees. Based on the above information gathered allegations are substantiated at this time.
Following deficiencies observed cited. Exit interview held. Copy of report and appeal rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230207101044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/21/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4)To care, supervision, and services that meet their individual needs and are delivered	1 2 3 4 5 6 7	Administrator will provide a written plan for more timely response times to calls for assistance and provide the plan on or before 2/21/2023.
	8 9 10 11 12 13 14	by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on 6 out 8 resident interviews and record review, response times to calls for assistance have taken from 10 minutes to an hour. in some instances.	8 9 10 11 12 13 14	This poses/posed a potential health, safety or personal rights risk to persons in care.
Type B 02/21/2023 Section Cited CCR 87303(b)(1)	1 2 3 4 5 6 7	87303 (b)A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement is not met as evidenced by: Based on observation the temperature	1 2 3 4 5 6 7	Administrator Agreed to create a plan to ensure the facility rooms are maintained at a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C). At this time the Licensee contacted a technician and they are currently working to resolve the issue.
	8 9 10 11 12 13 14	inside resident 1's (R1) room observed at 58 degrees Fahrenheit. Six (6) out of eight residents interviewed reported facility temperature is not maintained and it is too cold. This poses/posed a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	Temporarily, Licensee purchased safe individual heaters for the residents room. Administrator agreed to submit completed work order to show that the issue with the facility heating/cooling system is resolved.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

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