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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204374
Report Date: 09/26/2022
Date Signed: 09/26/2022 02:49:01 PM

Document Has Been Signed on 09/26/2022 02:49 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SIMLA VILLAS INC.FACILITY NUMBER:
198204374
ADMINISTRATOR:SIMLA MEHTAFACILITY TYPE:
740
ADDRESS:16623 ARDMORE AVENUETELEPHONE:
(562) 804-3603
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 15CENSUS: 13DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Jeniffer BobadillaTIME COMPLETED:
03:08 PM
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On 9/26/22 at 01:00 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Jeniffer Bobadilla and House Manager Dananjana Franklin who assisted with today’s visit.

The facility is licensed to serve 15 residents, ages 60 and above, 11 may be non-ambulatory and 4 bedridden. The facility has an approved hospice waiver for 4. The facility is a single-story building in a residential area, with a kitchen, dining room, living room, 9 bedrooms, 1 live in staff bedroom, 3 bathrooms, 1 staff bathroom, back yard with shaded area, detached garage and detached shed. Fire extinguisher observed fully charged throughout. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.



LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed 3 staff files, and reviewed 5 resident medications.

Report continued 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SIMLA VILLAS INC.
FACILITY NUMBER: 198204374
VISIT DATE: 09/26/2022
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Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The backyard are well maintained. The resident bathrooms are clean, and showers have non-skid matts and grab bars. The hot water temperature measured at 105.8- 109.5 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE in the garage. Infection control signs were observed throughout the facility. Medications reviewed for 5 clients and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6055379740 expire 3/16/2024. Last emergency disaster drill 9/8/22.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC809 (FAS) - (06/04)
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