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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850145
Report Date: 01/31/2022
Date Signed: 02/02/2022 02:13:24 PM

Document Has Been Signed on 02/02/2022 02:13 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:PALS WTC SIMI VALLEYFACILITY NUMBER:
565850145
ADMINISTRATOR:ROMERO, CHRISTOPHERFACILITY TYPE:
775
ADDRESS:1494 MADERA ROAD, SUITE A1TELEPHONE:
(805) 842-9505
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 45CENSUS: 21DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Christopher RomeroTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 10:35 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Program Director Christopher Romero and explained the reason for the visit.

The LPA toured the physical plant areas to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The Program Director tests the carbon monoxide and smoke alarms monthly and keeps a log indicating all function properly.

KITCHEN: Knives and cleaning supplies are stored in nearby locked cabinets. The facility has a sufficient supply of non-perishable food.

RESTROOMS: Restrooms are clean and sanitary and in operating condition.

COMMON SPACES: At the time of the visit, furnishings were observed to be in good condition. The LPA observed the required postings throughout the facility.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Program Director regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. There is also a central exit point to screen clients prior to leaving the day program. All facility staff were observed wearing masks. The LPA observed 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.

No deficiencies were observed. Exit interview conducted and a copy of the report emailed to Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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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