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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610046
Report Date: 09/25/2023
Date Signed: 09/25/2023 06:27:40 PM


Document Has Been Signed on 09/25/2023 06:27 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:HEARTLAND SENIOR LIVING AT SUNNYDALEFACILITY NUMBER:
567610046
ADMINISTRATOR:STRELLNER, JOHNFACILITY TYPE:
740
ADDRESS:704 ERRINGER RDTELEPHONE:
(805) 306-0021
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
09/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct an annual visit. Upon arrival LPA met with staff and explained reason for visit. Staff contact Licensee/Administrator John Strellner who stated that he is unable to be present today and authorized staff present to assist LPA with annual visit.
LPA and staff toured the physical plant areas inside and outside upon arrival to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke detector were tested and all functioned properly. The fire extinguisher appeared fully charged and was serviced last on 07/14/2023. KITCHEN: Knives 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. BEDROOMS: The LPA observed one double-occupancy bedroom and four single-occupancy bedrooms furnished appropriately with required furniture. RESTROOMS: There are two restrooms for residents use; observed clean and sanitary and in operating condition. 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 residents' use. The pool is fenced and locked/inaccessible. MEDICATIONS: Medications check at approximately 11-11:30 a.m.; Medications observed stored inaccessible in the living room in the drawer space by the desk. Complete accurate Centrally Stored Medication records observed on file for each resident; Medication administration record also observed on file. Medications are given accordingly by physician orders. RESIDENT and STAFF FILES: reviewed at approximately 12pm: Resident files observed complete with all required forms; Staff files reviewed observed complete with all required forms and training. Emergency and disaster drill reviewed with Mr. Strellner. Copy of the following shall be submitted: emergency and disaster drill;current LIC500 and liability insurance.
No deficiencies cited during today's visit. Exit interview held. Copy of report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023
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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