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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610007
Report Date: 01/24/2023
Date Signed: 01/26/2023 03:43:16 PM


Document Has Been Signed on 01/26/2023 03:43 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: 80DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Margie VeisTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPA) Zabel Chochian conducted an unannounced Required Annual inspection. This annual had a specific emphasis on infection control practices and procedures. Upon arrival LPA met with front desk staff and following with Administrator Margie Veis. Reason for visit was explained.

LPA and staff toured the physical plant areas to ensure the facility is in compliance with Title 22 Regulations.
INFECTION CONTROL: During today’s visit, LPA spoke with the staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. Sings observed throughout the facility common areas for proper hand washing, The LPA observed an adequate supply of Personal Protection Equipment (PPE) and cleaning supplies. Inventory of supplies maintained by staff to ensure they don't run out.

The facility’s cleaning protocol explained during todays visit is sufficient. Activity rooms and common spaces in both the Memory Care Unit and the Assisted Living areas appeared clean and in good repair.

The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19

The fire extinguishers observed just serviced this month 1/2023. LPA was informed that the Smoke Detectors and Carbon Monoxide detectors were just tested last week and cleared. Administrator agreed to submit copy of the clearance for the smoke detectors and carbon monoxide to LPA within two weeks.

Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
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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