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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609958
Report Date: 03/25/2022
Date Signed: 03/25/2022 10:57:31 AM

Document Has Been Signed on 03/25/2022 10:57 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:TREMONT HOME CARE, INC.FACILITY NUMBER:
567609958
ADMINISTRATOR:GRAHAM, LISAFACILITY TYPE:
735
ADDRESS:6694 TREMONT CIRCLETELEPHONE:
(805) 553-8451
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 2DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Lisa GrahamTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced One Year Infection Control Annual Visit. LPA met Tri-Counties Regional Center Quality Assurance Specialist Katy Robison and Administrator Lisa Graham at the facility and reason for visit was explained.

A physical plant tour was conducted between 8:30am - 9am, by LPA Chochian, Katy Robison and Administrator.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. 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. PPE, cleaning and disinfecting supplies observed sufficient during todays visit.

No deficiencies cited.

Exit interview conducted. Signatures obtained. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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