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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850330
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:36:42 PM

Document Has Been Signed on 04/16/2024 02:36 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:VENUS RESIDENTIALFACILITY NUMBER:
565850330
ADMINISTRATOR/
DIRECTOR:
URAMOTO, TODD KAZUYUKIFACILITY TYPE:
735
ADDRESS:1871 BURCH AVETELEPHONE:
(818) 518-8701
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 3DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Todd Uramoto - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 10:20am. No one was available on site. LPA contacted Administrator Todd Kazuyuki Uramoto and informed them they're at the facility. Administrator arrived at approx 11:30am , upon arrival LPA explained the reason for the visit. The LPAs 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.

LPA inspected facility for fire safety, personal accommodations, and food service. The facility smoke alarm and combined carbon monoxide system is hard wired and was functional during the inspection. There is one fire extinguisher in the kitchen.

The home capacity is for 4 ambulatory individuals. The facility is a single-story home consisting of a living room, dining room, kitchen, activity area, 5 total bedrooms (4 for client use), 1 bathroom. There is a covered backyard patio and garden area which wraps around and exits on the side of the house.

At approximately 11:30am, LPAs inspected client bedrooms.  The client bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each client The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed bathroom to be clean, properly supplied and had functional fixtures. The hot water was measured in the bathroom within 105 - 120 degrees Fahrenheit. The bathroom were sufficiently stocked with supplies and paper towels. The LPAs observed required postings throughout the common spaces.

The common areas were appropriately furnished, and the lighting was adequate. There are games and/or activity supplies in the living room as well as in client's room.  There was sufficient space to accommodate both indoor and outdoor activities.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: VENUS RESIDENTIAL
FACILITY NUMBER: 565850330
VISIT DATE: 04/16/2024
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Continued from 809
Night lights were maintained in hallways and passageways to non private bathrooms.  In addition, the physical plant is consistent with the submitted facility sketch/floor plan.  The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries.  The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

LPA inspected kitchen at approx. 11:45am ,  Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

Records review began at 12pm, client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.  All records were observed to be in order at this time.

The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was observed stored inaccessible in the medication cabinet as well. Medications review began at approximately at 1pm. The medications are centrally stored in a locked cabinet to the left of the sink. Medications are properly documented on the centrally stored medications and destruction record.

Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate at this time.
No clients or staff were on site to conduct interviews.
LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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