567610046-8-17-2021-29-AS-MGCZ-C5YRUU-20210817132032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610046
Report Date: 08/17/2021
Date Signed: 08/17/2021 01:21:30 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: 2	DATE:	08/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:26 AM
MET WITH:	John Strellner		TIME COMPLETED:	01:20 PM

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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced visit to Heartland Senior Living at Sunnydale to conduct a Required 1-Year Annual Inspection with focus on Infection Control. No previous Annual has been conducted since they were pre-licensed on 9-09-2020. LPA was greeted and screened at the door by Administrator John Strellnar and was explained the reason for the visit.

LPA 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. LPA along with Administrator John, initiated a tour at 12:36 PM and the following was observed:

There is a central entry point designated for universal screening by the entrance. Smoke detectors and Carbon Monoxide detector were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged. First-Aid Kit and Medications were observed in the living room in a locked cabinet. Main temperature displayed by hallway and read at 76 degrees Fahrenheit for the facility.

OUTDOOR SPACE: LPA observed the backyard to have a covered outdoor area with a tables and chairs for resident use. Large body of water (pool) always remains locked, inaccessible to residents. There is one (1) gate that has a single latch and always remains unlocked.

KITCHEN: LPA observed the kitchen/dining area to be clean. Knives are stored in a locked cabinet inside the garage. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a night stand, and adequate lighting.

Continued on LIC 809c

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

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: 08/17/2021

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Conitnued from LIC 809

RESTROOMS: LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. Water temperature was checked in two (2) resident bathrooms and are in compliance at 114.8 degrees Fahrenheit for bathroom #1 and 116.6 degrees Fahrenheit for bathroom #2.

LPA observed at least a 30-day supply of Personal Protection Equipment (PPE). The facility cleans the common areas at least twice daily. There are signs posted throughout the facility showing cough/sneeze etiquette, social distancing and how to properly wash hands. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. LPA observed CDSS PINs posted by the entrance accessible to both residents and visitors. LPA encouraged Administrator to have staff fit tested for N95 masks due to rising numbers in positive cases.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Exit interview conducted. A copy of the report were provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC809 (FAS) - (06/04)

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