567610007-1-20-2022-29-AS-BBAI-CAUUV8-20220120145443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610007
Report Date: 01/20/2022
Date Signed: 01/20/2022 03:07:43 PM

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:	VARENITA OF SIMI VALLEY		FACILITY NUMBER:	567610007
ADMINISTRATOR:	VEIS, MARGIE		FACILITY TYPE:	740
ADDRESS:	3921 COCHRAN STREET		TELEPHONE:	(805) 327-1100
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	110	CENSUS: 0	DATE:	01/20/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Margie Veis - Executive Director		TIME COMPLETED:	03:00 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) Brian Balisi conducted a Pre-licensing visit to the above facility. LPA met with Executive Director Margie Veis and explained the reason for the visit. At 10:30am, LPA conducted physical plant along with Administrator and Maintenance Director Victor Ruelas LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. Smoke detectors and Carbon Monoxide detectors appeared to function properly during time of visit. Facility is a 2 story residence and consists of a total of (102) apartments. Fire clearance was approved for all rooms for non- ambulatory residents and All rooms are approved for bedridden use, but maximum capacity shall be limited to (10). Fire extinguishers were observed throughout the facility and appeared to be fully charged , Ruelas stated they are due for thier annual service next month. During physical plant tour LPA observed the required postings throughout the facility. Kitchen: The kitchen was observed to be only accessible to staff. The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Emergency food supply was observed to be stored in a storage closet across the hall from the kitchen. LPA observed emergency food supply to be sufficient at this time. Dining furniture in dining room area appeared to be clean and sufficient at this time. Common Areas: These included Bistro, Painting areas, Gym, dining areas and multiple activity areas on 2^nd floor, The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Planned activities and games were on display on tables set up in each activity area. PPE was observed to be stored in storage closet near movie theater room. LPA observed PPE supply to be sufficient at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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 2

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: VARENITA OF SIMI VALLEY	FACILITY NUMBER: 567610007
	VISIT DATE: 01/20/2022

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
26
27
28
29
30
31
32

Continued from 809

Bedrooms: LPA inspected (10) randomly chosen rooms during physical plant. The resident bedrooms were observed to be properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Each bedroom had a private bathroom, LPA observed each bathroom to be clean, properly supplied and had functional fixtures. LPA observed all resident bathrooms to have grab bars and non-slip material in showers The hot water was measured in each bathroom inspected between 107 - 113 degrees Fahrenheit.

Memory Care: LPA inspected (3) randomly chose rooms during physical plant. The resident bedrooms were observed to be properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Each bedroom had a private bathroom. LPA observed each bathroom to be clean, properly supplied and had functional fixtures. LPA observed all resident bathrooms to have grab bars, non-slip material in showers and locked cabinets. The hot water was measured between 106 - 113 degrees Fahrenheit. There was an enclosed outdoor courtyard for memory care residents to use. Each door in the courtyard led back into Memory care wing. Laundry room for the facility was located in locked room across from memory care. There are also washer and dryers in each apartment. Margie stated that residents laundry will be completed by staff in each resident's room.

Outdoor Area: There was a shaded outdoor courtyard across from the main entrance of the facility with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. LPA observed laundry area next to memory care wing.

Comp III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. An exit interview was conducted with Executive Director and a hard copy was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2