567610046-9-19-2024-29-AS-VCOY-D99KYK-20240919081917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610046
Report Date: 09/18/2024
Date Signed: 09/19/2024 08:19:38 AM

Document Has Been Signed on 09/19/2024 08:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 4	DATE:	09/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	John Strellner		TIME COMPLETED:	03:00 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) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with Administrator, John Strellner and explained reason for visit. Entrance interview conducted. Starting at 10:00 A.M., the LPA, along with Administrator, 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. The following was observed: Kitchen: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food at the time of the visit. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 residents. Clining supplies are stored in a locked under-sink cabinet. There were no visible immediate hazards observed. At 10:17 A.M. hot water temperature measured at 114.9 degrees Fahrenheit. Fire extinguisher is fully charged, and recently purchased on 07/13/2024. Combination smoke alarms and carbon monoxide detectors were tested at 1:36 P.M. and were operational at this time. Bedrooms: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms. This facility doesn’t have a staff room, facility provides 24/7 care. Room #3 is cleared as a bedridden room. LPA observed that Room #3 is equipped with a fire door, and it has a direct exit to the backyard in case of an emergency. At the time of the visit, LPA observed fire door closed. No bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Continues on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEARTLAND SENIOR LIVING AT SUNNYDALE	FACILITY NUMBER: 567610046
	VISIT DATE: 09/18/2024

NARRATIVE

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Continued from LIC 809

Bathrooms: The LPA observed two (2) shared bathtrooms. Resident bathrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. All bathrooms were supplied with appropriate paper and hygiene products. Water temperatures were measured in all resident bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.

Common spaces: In the common areas walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The facility maintained a comfortable temperature of 73 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. Next to the living room there is an office area. Here, LPA, observed a working phone available for residents use whenever needed. Next to the office desk, there is a locked file cabinet where both staff and resident files, along with medications, are securely stored. There is a fireplace in the Dining Room, which was observed to be adequately screened. During today’s inspection, LPA observed, a closed fire door separating the common areas and kitchen from bedrooms and bathrooms. Fire door was closed at the time of the visit.

Outdoor Space: The backyard area contains a shaded area with a table and chairs for resident use. There are 2 side gate doors with self-latching mechanisms. Passageways were observed to be clear and free of hazards. LPA observed an in-ground swimming pool. The pool is kept inaccessible to residents with the use of fencing that includes a locked gate on both sides of the backyard, ensuring that access is restricted. The LPA mentioned that facility requires a Water Safety Certification for staff providing supervision during pool use and that qualified staff must be present at all times that the pool is in use by residents.

Garage: The garage is where the washer and dryer are held, including emergency food and emergency water. Cleaning supplies and disinfectants are kept in locked cabinets in the garage all cleaning compounds were stored in areas separately from food supplies. All knives were observed to be locked and kept in the garage inaccessible to residents.

Continued from LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEARTLAND SENIOR LIVING AT SUNNYDALE	FACILITY NUMBER: 567610046
	VISIT DATE: 09/18/2024

NARRATIVE

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Continued from LIC 809-C

File review: A review of facility files was initiate at 11:35 A.M. and the following was observed. LPA reviewed four (4) residents files and four (4) staff file including the administrator’s. All documents reviewed appeared complete and current. LPA obtained Client Roster, Staff Roster, and Liability insurance. Last emergency drill was conducted on 08/14/2024.

Medication review: Began at 1:10 P.M.; LPA reviewed medication log for all four (4) residents. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

No deficiencies cited at this time. Exit interview conducted. Report issued and provided to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

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