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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850167
Report Date: 11/22/2022
Date Signed: 11/22/2022 04:55:17 PM


Document Has Been Signed on 11/22/2022 04:55 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:CASA BLANCA SENIOR LIVINGFACILITY NUMBER:
565850167
ADMINISTRATOR:VIGIL, MONICAFACILITY TYPE:
740
ADDRESS:5631 EUNICE AVE.TELEPHONE:
(805) 218-0397
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:4CENSUS: 3DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Monica VigilTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with Administrator Monica Vigil and explained the reason for the visit. The LPA and Administrator toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: four out of five rooms are for resident use; one bedroom is a staff room. Bedrooms had appropriate furnishings, clean linens and sufficient lighting. RESTROOMS: Resident restrooms were clean and sanitary with grab bars and non-skid surfaces. The LPA observed hand hygiene signs in all restrooms. COMMON SPACES: Living room and dining furniture were observed to be in good condition. Exits have functioning auditory devices. Fire extinguisher charged and serviced in the last twelve months. BACKYARD: There were no bodies of water noted at the time of the visit.

INFECTION CONTROL: There is a central entry point for universal screening and temperature checks. Staff were observed wearing appropriate face masks. There is a centralized location for COVID-19 signs to promote hand hygiene, physical distancing, and cough/sneeze etiquette. There is sanitizer available for use throughout the facility. There is an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19 (all private rooms). The policies and procedures pertaining to infection control observed adequate at the time of visit.

No deficiencies observed at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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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