<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610003
Report Date: 10/24/2023
Date Signed: 10/26/2023 01:20:49 PM

Document Has Been Signed on 10/26/2023 01:20 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: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: 4DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kenneth Carpenter & Arthur J. HarrisTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required annual visit. LPA met with staff Arthur H. and later with Administrator Kenneth Carpenter. Reason for visit was explained.

The LPA and staff toured the physical plant areas inside and outside at approximately (aprox.) 10:30am to ensure there are no health and safety hazards. BEDROOMS: LPA observed four single-occupancy resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.RESTROOMS: There are two resident restrooms which were observed clean, sanitary, and in operating condition with grab bars and non-skid surfaces at the time of visit. Sufficient amounts of soap and paper products observed. Hot water was measured at 108.8*F. COMMON SPACES: Common area walls and flooring were observed for cleanliness and good condition. At the time of the visit, living room and dining room furniture observed to be in good condition. BACKYARD: No bodies of water noted. Trailer observed on the side of the house; used by off duty staff only. The garage contains additional nonperishable and perishable food items. Cleaning supplies were in a locked cabinet in the garage. LPA observed an adequate supply of Personal Protection Equipment (PPE). 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. Smoke and carbon monoxide detector tested/operable during visit. Fire extinguisher was observed to be fully charged and last inspected 10/15/23. MEDICATIONS: Medications were stored in a locked cabinet. Medication administration records and centrally stored medication logs reviewed at approximately 11am. Medications and logs were consistent. RESIDENT FILES: All resident files reviewed at 11:30am. Resident files included a current medical assessments, appraisals, consent forms, and admission agreements. STAFF FILES: Reviewed at 12:45pm. Files included current first aid and training records. All staff have criminal record clearance and are associated to facility.


LPA informed Administrator to submit a current LIC500; liability insurance and surety bond. Also advised administrator to update all records to current facility and licensee name. No deficiencies cited at this time. Exit interview conducted, and a copy of the report was provided by email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1