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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610003
Report Date: 09/27/2022
Date Signed: 09/30/2022 09:13:10 AM

Document Has Been Signed on 09/30/2022 09:13 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:CALIFORNIA NEEDS AND SERVICESFACILITY NUMBER:
567610003
ADMINISTRATOR:KENNETH CARPENTERFACILITY TYPE:
735
ADDRESS:2630 COCHRAN STREETTELEPHONE:
(805) 209-5819
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 3DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Kenneth CarpenterTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 2:13 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Licensee/Administrator Kenneth Carpenter and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards.
BEDROOMS: The LPA observed four single-occupancy resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There were two resident restrooms which were clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. Hot water was measured at 115.2*F. KITCHEN: Kitchen appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture were observed to be in good condition. Medications were stored in a locked cabinet in the dining room. One fire extinguisher was observed to be fully charged and last inspected by the fire department 9/2021. BACKYARD: The backyard has a covered outdoor area equipped with furniture for client use. There were no bodies of water noted. The garage contains additional nonperishable and perishable food items. Cleaning supplies were in a locked cabinet in the garage. INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed 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 does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control. No deficiencies cited at this time. Exit interview conducted, and a copy of the report was provided by email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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