567610046-9-9-2020-29-AS-ASMH-BTAUKL-20200909153920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610046
Report Date: 09/09/2020
Date Signed: 09/09/2020 03:39:43 PM

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:	HEARTLAND SENIOR LIVING AT SUNNYDALE		FACILITY NUMBER:	567610046
ADMINISTRATOR:	STRELLNER, JOHN		FACILITY TYPE:	740
ADDRESS:	704 ERRINGER RD		TELEPHONE:	(805) 306-0021
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 0	DATE:	09/09/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	John Strellner		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Smith conducted an announced pre-licensing visit at 1pm. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing visit was conducted via FaceTime with applicant John Strellner. This is a new facility. A Dementia Waiver and Hospice Waiver has been requested. The applicant successfully completed Component II on 5/28/2020 and Component III will be conducted in conjunction with this pre-licensing visit. Bedrooms: The physical plant was toured inside and out. A fire clearance was approved on 6/25/2020 for six (6) non-ambulatory residents. Room #3 was approved as a bedridden room. The facility has five (5) bedrooms and two (2) bathrooms. Rooms #1, #3, #4, and #5 are private bedrooms, whereas Room #2 is a shared bedroom. Room #3 have a direct exit to the outside. There are no staff rooms and there will be awake night staff only. Rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms appeared adequate. Bathrooms: There are two full bathrooms. Bathrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid mats. At 2:40pm, the LPA asked the applicant to test the water in the common hallway bathroom. The hot water measured at 106 degrees Fahrenheit. Kitchen: Kitchen knives will be stored in a locked cabinet in the garage. The supply of food (ie. perishable, nonperishable, and emergency supply) was adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet in the garage. At 2:38pm, the hot water was tested by the applicant, and the water registered at 120 degrees Fahrenheit. CONT 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

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: HEARTLAND SENIOR LIVING AT SUNNYDALE	FACILITY NUMBER: 567610046
	VISIT DATE: 09/09/2020

NARRATIVE

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Common Areas: The common areas were appropriately furnished, and the lighting was adequate. There is entertainment and activity equipment in the living room and common area. Resident and staff records will be stored in a secured cabinet in the garage. There is a screened fireplace in the living room. Medications will be locked inaccessible in a cabinet in the living room. The supply of extra bed and bath linens is adequate.

At 1:55pm, the hard-wired smoke and carbon monoxide detectors were tested and were operational at the time of the inspection. There is one fire extinguisher, which was purchased 5/2020. Alarms on all exterior doors were engaged at the time of visit. There is a functioning telephone on the premises. Emergency lighting was observed throughout the facility. Emergency exiting plans/sketch, emergency telephone numbers, and other required postings are posted in the living room.

Outside: The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is fenced. There is a self-latching gate for persons to enter the front yard. There is a locked storage shed in the back yard. There is an observed pool, that is appropriately fenced and is self-latching at the top of the gate.

Garage: The garage is attached to the house and will be kept locked. The washer and dryer is kept in the garage.

Component III was conducted with applicant in conjunction with this visit.

The physical plant is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Exit interview conducted and report issued via email for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

LIC809 (FAS) - (06/04)

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