567610007-1-27-2025-29-AS-MARO-DDBVWG-20250127154754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610007
Report Date: 01/27/2025
Date Signed: 01/27/2025 03:48:13 PM

Document Has Been Signed on 01/27/2025 03:48 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 VALLEY		FACILITY NUMBER:	567610007
ADMINISTRATOR/ DIRECTOR:	VEIS, MARGIE		FACILITY TYPE:	740
ADDRESS:	3921 COCHRAN STREET		TELEPHONE:	(805) 327-1100
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 110	TOTAL ENROLLED CHILDREN: 0	CENSUS: 97	DATE:	01/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Margie Veis		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted an unannounced annual inspection. Upon arrival, the LPAs met with Executive Director (ED), Margie Veis and explained the reason for the visit. Entrance interview conducted.

Beginning at 10:10am, the LPAs started reviewing records which included the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The last fire safety inspection was completed on 01/15/2025 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill on 12/31/2024.

Beginning at 11:15am, the LPAs along with the Executive Director, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

RESIDENT ROOMS/RESTROOMS: The LPAs observed five resident rooms and their accompanying restrooms were observed during today's facility tour. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Beginning at 11:30am, the hot water temperature was measured in four assisted living bathrooms and one memory care bathroom, and the temperature measured between 113.4 – 118.4 degrees Fahrenheit.

Report Continued on LIC 809C...

Desaree Perera	TELEPHONE: (818) 596-4347
Martha Arroyo	TELEPHONE: (818) 421-6459
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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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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: 01/27/2025

NARRATIVE

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Report Continued from LIC 809...

KITCHEN: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked.

COMMON AREAS: The LPAs observed common areas to be clean and in good condition. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 1/07/2025. The LPAs observed hand sanitizer stations throughout the facility.

OUTDOOR SPACE: The LPAs observed the outdoor garden in Assisted Living and Memory Care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards.

RECORD REVIEW: The LPAs reviewed resident and staff records beginning at 12:35pm.

Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order.

Ten personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. Three out of ten staff files reviewed did not have up to date yearly training and Staff 1 (S1) was fingerprint cleared but not associated to the facility.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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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: 01/27/2025

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Report Continued from LIC 809C...

MEDICATION REVIEW: Beginning at 12:00pm, the LPAs reviewed medications for five residents. The medications are centrally stored in the medication room on the second floor. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record. Medications appear to be given as prescribed.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D).

Exit interview conducted. A copy of report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2025 03:48 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as S1 was hired by the facility on 04/29/2023 but have not been associated to the facility since 02/21/2024, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	S1 was re-associated to the facility during today's visit. POC has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Desaree Perera	TELEPHONE: (818) 596-4347
Martha Arroyo	TELEPHONE: (818) 421-6459
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/27/2025 03:48 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as three out of ten staff do not have the required annual training completed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	The Licensee will ensure all staff completes necessary yearly training and submit proof to CCLD no later than POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Desaree Perera	TELEPHONE: (818) 596-4347
Martha Arroyo	TELEPHONE: (818) 421-6459
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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