565850167-11-5-2021-29-AS-BBAI-C8GT84-20211105142942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850167
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:30:12 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:	CASA BLANCA SENIOR LIVING		FACILITY NUMBER:	565850167
ADMINISTRATOR:	VIGIL, MONICA		FACILITY TYPE:	740
ADDRESS:	5631 EUNICE AVE.		TELEPHONE:	(805) 218-0397
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 0	DATE:	11/05/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Monica Vigil - Administrator		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi conducted a Pre-licensing visit to the above facility. LPA met with Administrator Monica Vigil and explained the reason for the visit. At 10:00am LPA conducted physical plant along with Administrator. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. Smoke detectors and Carbon Monoxide detectors appeared to function properly during time of visit. Facility is a single-story residence and consists of a total of five (5) bedrooms and two (2) bathrooms with (1) bedroom is designated for staff use at this time. Fire clearance was approved for (6) non-ambulatory residents, but licensee stated since they are residing in bedroom #2 at this time they will be updating facility capacity from (6) to (4). Fire extinguishers were observed to be fully charged and purchased this year . During physical plant tour LPA observed the required postings throughout the facility. Kitchen: The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are to be stored in a locked cabinet in the kitchen next to the hallway. Medications are planned to be kept in this cabinet in individual medication lock boxes. LPA observed PPE supplies stored in this cabinet and appeared sufficient at this time. Cleaning supplies and toxins will be kept in a locked cabinet to the right of the sink. To the right of the kitchen was in office area. Dining furniture in kitchen and dining room area appeared to be clean and sufficient at this time. Continued on 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
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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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: CASA BLANCA SENIOR LIVING	FACILITY NUMBER: 565850167
	VISIT DATE: 11/05/2021

NARRATIVE

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Continued from 809

Bedrooms: The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet between bedrooms one and two,

Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed all resident bathrooms to have grab bars and non-skid mats. The hot water was measured in each bathroom between 112 - 113 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Planned activities and games were on display on a shelf in the living room.

Outdoor Area: There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There are no bodies of water on the premises. Garage was accessible from the exterior. LPA observed laundry area in the garage. LPA also observed (2) locked storage cabinets which stored extra cleaning supplies and garden supplies.

Comp III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. Licensee agreed to follow up with LPA to follow up on their capacity status once it has been changed. An exit interview was conducted with Administrator, and a hard copy was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
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

LIC809 (FAS) - (06/04)

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