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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850266
Report Date: 09/15/2023
Date Signed: 09/26/2023 09:46:11 PM


Document Has Been Signed on 09/26/2023 09:46 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:ALTA VISTA SIMI #2 LLCFACILITY NUMBER:
565850266
ADMINISTRATOR:REDLIN, VICTORIA N.FACILITY TYPE:
740
ADDRESS:2942 ROSETTE ST.TELEPHONE:
(805) 208-2345
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Emiliano Siapno, Assistant AdministratorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a required annual visit to the above noted facility. The LPA met with assistant administrator Emiliano Siapno. The facility is one-story. At approximately (aprox.) 4:15 p.m. a physical plant tour was conducted inside and out. The facility has two (2) double- occupancy resident bedrooms and two (2) single occupancy resident bedrooms. There are three full bathrooms in the house. The smoke detectors and carbon monoxide detectors were tested and functioned properly during the time of visit. There were three fire extinguishers located in or near the kitchen all observed fully charged/serviced. KITCHEN: Knives and sharp objects are stored in a locked cabinet in the kitchen. Cleaning supplies are stored locked and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms were fully stocked with soap and paper towels. Appropriate hand-washing signs were observed the bathrooms. Hot water temperature tested within required range. COMMON SPACES: Living room and dining room furniture was observed to be in good condition. All exits have functioning auditory devices. The LPA observed the required licensing postings listed throughout the facility. The backyard has a covered outdoor area equipped with furniture for resident use. The side gate door is self-latching. There were no bodies of water noted. The garage is locked. Washer and dryer are located in garage, including an additional refrigerator. The LPA observed an adequate supply of Personal Protection Equipment (PPE) stored in the garage and the facility is able to obtain additional supplies as needed. The exterior passageways were clean and clear of any obstructions. There is a patio area with a table, chairs and shade cover. The side gate is self-latching. There is a locked storage shed behind a locked gate. There are no bodies of water more than 3ft deep on the premise.
Resident records reviewed at approximately 4:30pm found to be complete with all required documents.
Due to time constraints, annual visit will continue at a later date. Exit interview held. Copy of report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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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