565850167-11-19-2024-29-AS-MARO-DB6TX7-20241119140641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850167
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:06:49 PM

Document Has Been Signed on 11/19/2024 02:06 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 LIVING		FACILITY NUMBER:	565850167
ADMINISTRATOR/ DIRECTOR:	VIGIL, MONICA		FACILITY TYPE:	740
ADDRESS:	5631 EUNICE AVE.		TELEPHONE:	(805) 218-0397
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS: 4	DATE:	11/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Monica Vigil		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were two (2) staff and four (4) residents present. The LPA was greeted by the Administrator, Monica Vigil and the reason for the visit was explained. Entrance interview conducted.

Starting at 10:44 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 10:44 a.m. Knives and sharps were observed locked and inaccessible in a kitchen drawer. The LPA observed cleaning supplies in a locked cabinet and under the kitchen sink inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 10:51 a.m., the hot water temperature was measured in the kitchen sink, and it measured at 114.6 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be fully charged with a date of 04/23/2024. Required postings were observed throughout the common space. The LPA observed a fireplace adequately covered at the time of the visit. Activities were observed in the living room and dining room. There is a working telephone on premises. Cameras observed in the common areas. The LPA observed a closet in the hallway with additional clean linens and towels. Auditory alarms were observed at the time of the visit.

Report Continued on LIC 809...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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: 11/19/2024

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Report Continued from LIC 809...

RESTROOMS: There are two (2) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:13 a.m., the hot water temperature was measured in both bathroom and they measured between 109.2 and 113.5 degrees Fahrenheit.

BEDROOMS: There are four (4) bedrooms for resident use. All bedrooms are designated as private rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff bedroom on premises.

GARAGE: The garage was locked and inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water. Washer and dryer were observed inside the garage. Additional cleaning supplies are kept in the garage locked and inaccessible to residents in care.

BACKYARD: The backyard has a covered patio area with patio furniture for resident use. The LPA observed a locked shed for storage purposes. All passageways were observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms. No bodies of water noted at the time of the visit.

RECORDS: LPA reviewed Resident Records at 9:23 a.m. and Personnel Records at 10:03 a.m.

Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order.

Six (6) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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: 11/19/2024

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Report Continued from LIC 809C...

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill which was conducted on 09/23/2024.

MEDICATIONS: Medications review began at approximately 11:30 a.m. The medications are locked in a cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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