565850357-9-19-2023-29-AS-MARO-CVTPWN-20230919114100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850357
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:41:05 AM

Document Has Been Signed on 09/19/2023 11:41 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:	AMERICA'S CARE		FACILITY NUMBER:	565850357
ADMINISTRATOR:	CALLES, MARIA D		FACILITY TYPE:	740
ADDRESS:	5763 KATHERINE ST		TELEPHONE:	(818) 448-8641
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 0	DATE:	09/19/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Maria Calles		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA), Martha Arroyo conducted a pre-licensing visit to this property at 9:15 a.m. on 09/19/2023 and met with Applicant Representative Maria Calles. The applicant has obtained fire clearance for a total capacity of four (4) non-ambulatory residents, and two (2) bedridden residents in bedrooms #2 and #4 for a total capacity of six (6) residents. The facility has a dementia program in place.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 9:45 a.m., all hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. LPA observed one (1) fire extinguisher to be new and fully charged on 05/03/2023.

There are four (4) single occupancy bedrooms and one (1) double occupancy bedroom for resident use and one (1) staff room / office. Each bedroom is equipped with clean mattresses, pillows, and bedding. There is a closet in the hallway with a sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has two (2) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Hot water temperature was measured in both bathrooms; first bathroom measured 115.3 degrees Fahrenheit at 9:28 a.m.; and second bathroom measured 113.9 degrees Fahrenheit at 9:32 a.m.

LPA toured the kitchen area at 9:35 a.m. The facility has at least seven (7) day supply of non-perishable food and two (2) days perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives and cleaning supplies were observed under the kitchen sink locked and inaccessible. The kitchen has a sufficient supply of plates, cups, cookware and utensils. Hot water temperature was measured in the kitchen at 116.7 degrees Fahrenheit at 9:37 a.m.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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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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: AMERICA'S CARE	FACILITY NUMBER: 565850357
	VISIT DATE: 09/19/2023

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(Report Continued from LIC 809...)

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There are activity supplies in the living room. Night-lights were present in the main hallway and common areas. All doors have functioning auditory alarms when opened.

Facility will have one central entry point designated for universal screening. Alcohol-based hand sanitizer and masks available upon entry. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE).

Medications and facility records are stored and locked in a file cabinet adjacent to the kitchen. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual.

Garage: The garage is attached to the house and is locked at all times. The laundry room is inside the garage. Detergents, disinfectants, and cleaning supplies are stored and inaccessible. There will be no firearms/ammunition stored on the property. There is a sufficient supply of emergency food and water.

The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.

The exterior passageways were clean and clear of any obstructions. There are two (2) self-latching gates for emergency use. There are no bodies of water on the premises at the time of the visit. LPA observed the backyard, which has a covered outdoor area with a table and chairs for resident use. Physical plant is consistent with the submitted facility sketch/floor plan.

Physical plant is consistent with the submitted facility sketch / floor plan.

Comp III conducted with Applicant Representative.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. The report was reviewed and a copy was provided to Applicant Representative Maria Calles.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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