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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609948
Report Date: 04/12/2022
Date Signed: 04/12/2022 12:08:43 PM

Document Has Been Signed on 04/12/2022 12:08 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:ALTA VISTA SIMI, LLCFACILITY NUMBER:
197609948
ADMINISTRATOR:SIAPNO, EMILIANOFACILITY TYPE:
740
ADDRESS:2624 RUDOLPH DRIVETELEPHONE:
(760) 613-6480
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 6DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Emil SiapnoTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Administrator Emil Siapno and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

KITCHEN: Knives and sharp objects are stored in a locked cabinet in the kitchen. Cleaning supplies are stored locked and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: Resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms were fully stocked with soap and paper towels. Appropriate hand-washing signs were observed the bathrooms. Staff and the LPA tested the water temperature, and the hot water temperature measured within range.

COMMON SPACES: The LPA observed COVID-19 signage that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. At the time of the visit, living room and dining room furniture was observed to be in good condition. All exits have functioning auditory devices. The LPA observed the required licensing postings listed throughout the facility.

The backyard has a covered outdoor area equipped with furniture for resident use. The side gate door is self-latching. There were no bodies of water noted. The garage is locked. The garage is where the washer and dryer are held, including additional nonperishable and perishable food items. The LPA observed an adequate supply of Personal Protection Equipment (PPE) stored in the garage and the facility is able to obtain additional supplies as needed.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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: ALTA VISTA SIMI, LLC
FACILITY NUMBER: 197609948
VISIT DATE: 04/12/2022
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INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19, as each resident has their own room. This facility has records of staff and resident vaccinations. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The facility’s policies and procedures pertaining to infection control were adequate.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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