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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609984
Report Date: 06/16/2022
Date Signed: 06/16/2022 01:46:19 PM


Document Has Been Signed on 06/16/2022 01:46 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:BUENAVILLE ASSISTED LIVING, LLCFACILITY NUMBER:
567609984
ADMINISTRATOR:BUENAFE, NASHERFACILITY TYPE:
740
ADDRESS:5629 PITTMAN STTELEPHONE:
(805) 791-3947
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nasher BuenafeTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. This annual visit had a specific emphasis on infection control practices and procedures. The LPA met with Nasher Buenafa and reason for visit was explained. At approximately 1pm today, LPA and Mr. Nasher toured the physical plant areas inside and outside to ensure the facility is in compliance with Title 22 Regulations: KITCHEN: Knives are stored inaccessible to the clients. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.
BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: resident restrooms observed clean/sanitary and in operating condition. Restroom observed stocked with liquid soap and paper towels; appropriate hand-washing signs observed posted. COMMON SPACES: In the common areas, living room and dining room furniture observed to be in good condition. The appropriate licensing documents and infection control postings observed posted throughout the facility. The backyard observed hazardous free; with patio furniture for residents use. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The administrator's cleaning protocol is in place. Facility observed clean during todays visit.
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 does not have a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control appeared to be in compliance during todays visit. .
No deficiencies observed during todays visit. Exit interview conducted with Administrator.
Copy of report provide via email to Administrator.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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