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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610007
Report Date: 01/05/2024
Date Signed: 01/05/2024 02:20:21 PM


Document Has Been Signed on 01/05/2024 02:20 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:VARENITA OF SIMI VALLEYFACILITY NUMBER:
567610007
ADMINISTRATOR:VEIS, MARGIEFACILITY TYPE:
740
ADDRESS:3921 COCHRAN STREETTELEPHONE:
(805) 327-1100
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:110CENSUS: 100DATE:
01/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Margie VeisTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Incident visit for the purpose of investigating a self-reported incident report and SOC 341. Upon arrival, the LPA met with Executive Director (ED), Margie Veis, and explained the reason for the visit. Entrance interview.

On 01/02/2024, the Department received an incident report stating that on the morning of 01/01/2024, Staff #1 (S1) was assisting Resident #1 (R1) with dressing. R1 was resistant to care and became agitated. R1 slapped S1 across the face, causing S1’s glasses to fall off their face and in response, S1 slapped R1 across the face. Staff #2 (S2) witnessed the incident as they were inside the room assisting S1.

During today’s visit, the LPA conducted a tour of the Memory Care Unit to ensure there are no health and safety concerns at 12:20 p.m., conducted interviews with the ED and two staff between 12:13 p.m. and 12:45 p.m., conducted a file review at 1:05 p.m., and obtained copies of pertinent documents relevant to the investigation. LPA has determined further investigation is needed and will return at a later date to continue.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
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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