567610022-9-18-2023-29-AS-ZCHN-CVSTAF-20230918143329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610022
Report Date: 09/15/2023
Date Signed: 09/18/2023 02:34:00 PM

Document Has Been Signed on 09/18/2023 02:34 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:	APPLETON HOMES		FACILITY NUMBER:	567610022
ADMINISTRATOR:	OLIVAS, MYLINE		FACILITY TYPE:	740
ADDRESS:	1149 APPLETON RD		TELEPHONE:	(747) 237-0417
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 5	DATE:	09/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Myline Olivas		TIME COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a required annual visit at 12:50 p.m. The LPA met with Licensee/Administrator Myline Olivas and explained the reason for the visit.

At approximately 1:15pm, LPA and administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged and was last serviced 08/10/2023. KITCHEN: Knives are stored in a locked drawer and chemicals are stored in a locked cabinet in the garage adjacent to the kitchen. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. ceiling/lighting needs to be replaced/repaired. BEDROOMS: The LPA observed two double-occupancy and two single-occupancy client bedrooms and one staff room. Rooms were furnished appropriately. RESTROOMS: Restrooms are clean and sanitary. Wall behind the toilet in the first bathroom observed to have water damage. COMMON SPACES: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the facility. The backyard patio is equipped with furniture for clients' use. Side gate door is not self-latching. Spring needs to be installed to ensure gate self latches closed.

Client files reviewed (2pm): 4/4 client files were reviewed, no deficiencies were observed.

Staff files reviewed (2:30pm): LPA reviewed files for the administrator and 2/2 staff present today, no deficiencies observed.
Medications: At 3:15pm a random selection of client medications was reviewed. All appeared to be stored and administered according to doctors’ orders and applicable laws and regulations at this time.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):
Exit interview conducted, appeal rights explained. Copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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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Document Has Been Signed on 09/18/2023 02:34 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: APPLETON HOMES	FACILITY NUMBER: 567610022
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above: Both bathrooms and kitchen observed in disrepair. Bathroom wall observed damaged from either water or other; needs repair and fresh paint; Kitchen ceiling lighting observed in disrepair/out of order. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator stated she will discuss repairs with property owner and provide a plan and completion date of needed repairs by 9/25/2023.

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.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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