567609958-3-12-2024-29-AS-MARO-D3APVH-20240312113910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609958
Report Date: 03/12/2024
Date Signed: 03/12/2024 12:03:40 PM

Document Has Been Signed on 03/12/2024 12:03 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:	TREMONT HOME CARE, INC.		FACILITY NUMBER:	567609958
ADMINISTRATOR:	GRAHAM, LISA		FACILITY TYPE:	735
ADDRESS:	6694 TREMONT CIRCLE		TELEPHONE:	(805) 553-8451
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6		CENSUS: 3	DATE:	03/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Lisa Graham		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 8:30 a.m. The last annual conducted at this facility was on 02/17/2023. Upon arrival, the LPA met with Administrator, Lisa Graham, and at this time, the reason for the visit was explained. Entrance interview conducted.

At 8:34 a.m., the LPA along with the Administrator, 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. The following was noted:

KITCHEN: The LPA inspected the kitchen area at 8:37 a.m. At 8:42 a.m., the hot water temperature was measured, and it was found in compliance as it measured between 105- and 120-degrees Fahrenheit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The LPA observed knives and sharps in a locked box under the kitchen island.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 9:07 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. There is a functioning telephone on the premises. LPA observed an exercise room with additional activities for client use. First aid kit was observed to be complete.

Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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: TREMONT HOME CARE, INC.	FACILITY NUMBER: 567609958
	VISIT DATE: 03/12/2024

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Continued from LIC 809...

GARAGE/BACKYARD: The garage is attached and accessible to clients. Washer and dryer were observed inside the garage. Clients do their own laundry; however, the staff is present and assists if needed. LPA observed a sufficient supply of emergency food and water. The backyard has a covered outdoor area equipped with a table and chairs for client use. There is a shed with garden tools that was locked at the time of the visit. The facility has a side gate that self-closes. Passageways were observed clear and free of obstructions in case of an emergency. No bodies of water noted at the time of the visit.

BEDROOMS: There are three (3) double occupancy client bedrooms. The LPA observed the client bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a staff room on premises.

RESTROOMS: There is one (1) restroom for client use. The restrooms was clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathroom were sufficiently stocked with liquid hand soap and paper towels; towels and washcloths are not shared. The hot water temperature was measured, and it was found in compliance as it measured between 105- and 120-degrees Fahrenheit.

RECORDS: Records review began at 9:11 a.m.; three (3) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order.

One (1) personnel record was reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Record was complete.

The current Administrator’s file was also reviewed, and it was complete. Administrator’s certificate is active and expires on 05/10/2025

Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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: TREMONT HOME CARE, INC.	FACILITY NUMBER: 567609958
	VISIT DATE: 03/12/2024

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Continued from LIC 809C...

The facility is vendored by Tri-Counties Regional Center (TCRC). There are three (3) clients at this time; however, they were out in the community at the time of the inspection.

The last emergency disaster drill took place on 03/12/2024.

MEDICATIONS: Medications review began at approximately 10:45 a.m.; medications are centrally stored in a locked cabinet adjacent to the living room/office. All medications including PRNs were labeled, stored, and locked inaccessible to clients in care. Medications are properly documented on the centrally stored medications and destruction record.

No deficiencies were noted at this time. Exit interview conducted. Report was reviewed and a copy was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

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