565850261-7-21-2022-29-AS-ZCHN-CGJP9R-20220721110734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850261
Report Date: 07/20/2022
Date Signed: 07/21/2022 11:08:28 AM

Document Has Been Signed on 07/21/2022 11:08 AM - 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:	ABOVE AND BEYOND HOME CARE		FACILITY NUMBER:	565850261
ADMINISTRATOR:	SALUNGA, ALBERT		FACILITY TYPE:	740
ADDRESS:	6217 ANASTASIA ST		TELEPHONE:	(747) 210-1660
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 3	DATE:	07/20/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Albert Salunga		TIME COMPLETED:	03:00 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) arrived to this property for a pre-licensing inspection. The LPA met with applicant Albert Salunga. This is a change of ownership application from A Loving Care Villa (#565802448) to Above and Beyond Home Care (#565850261). The current census is at 3 residents. The fire clearance was granted on 04/29/2022; in which all rooms were cleared for non-ambulatory clients, in which a bedridden person is permitted in Bedroom #4. Applicant successfully completed Component II on 06/07/2022 and Component III during todays visit. The LPA toured the physical plant areas inside and outside with applicants to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives are stored locked and inaccessible in the closet in the hallway. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food. BEDROOMS: There are 4 bedrooms in the facility; two shared rooms and two private bedrooms for resident use. All rooms have direct access to the outside. Lighting in the rooms appeared adequate; set up with beds, night stands, lamps, chests of drawers, chairs and closet space. BATHROOMS: There are two bathrooms; bathtubs are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature within required range. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. The facility smoke alarm system is hard wired; one smoke detector observed to be dual smoke and carbon monoxide detector; all were operable at the time of the visit. There is a fireplace in the living room, which is appropriately screened. The fire extinguisher was fully charged and last serviced 07/2021. There is a functioning telephone on the premises. Emergency exiting plans/sketch observed posted; all other required postings are posted in the hallway upon entry into the facility. (continue)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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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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: ABOVE AND BEYOND HOME CARE	FACILITY NUMBER: 565850261
	VISIT DATE: 07/20/2022

NARRATIVE

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MEDICATIONS: Medications are in a locked cabinet adjacent to the kitchen. First aid kits were complete.

FILES: Staff and resident files are stored locked and inaccessible in the hallway closet. Resident and staff files observed complete.

GARAGE: The laundry area is set up in the garage. Laundry detergent and chemicals are stored inaccessible in a cabinet. An additional refrigerator is in the garage with perishable items in good condition.

GROUNDS: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water on the premises at the time.

INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Facility is in compliance with Title 22 Regulations at this time. The CAB Analyst will notify the applicant when the license has been approved. Exit interview conducted and report issued..

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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