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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610007
Report Date: 09/17/2024
Date Signed: 09/17/2024 03:24:13 PM


Document Has Been Signed on 09/17/2024 03:24 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: 99DATE:
09/17/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Margie VeisTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced cased management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with Executive Director (ED), Margie Veis and the reason for the visit was explained. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations.

During today’s visit, the LPA along with the ED and Maintenance Director conducted a walk through of the facility at 1:35pm. Five (5) randomly selected resident bedrooms were observed. Resident rooms were observed to be furnished appropriately with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. Hot water temperature was measured in three (3) bedrooms in assisted living; and two (2) bedrooms in memory care. Water temperature measured within 105- and 120-degrees Fahrenheit. Fire extinguishers were observed throughout the facility fully charged on 01/16/2024. The facility has a sufficient supply of perishable and non-perishable food. No obstructions or hazards were observed inside or out. Additionally, the LPA and ED discussed the new resident Admissions Agreement and Assessment Tool submitted to CCL as it needs to be updated to meet Title 22 Regulations.

No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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