198204374-8-5-2024-28-AS-THEA-D7URMM-20240805130857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204374
Report Date: 08/05/2024
Date Signed: 08/05/2024 01:09:03 PM

Document Has Been Signed on 08/05/2024 01:09 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	SIMLA VILLAS INC.		FACILITY NUMBER:	198204374
ADMINISTRATOR/ DIRECTOR:	SIMLA MEHTA		FACILITY TYPE:	740
ADDRESS:	16623 ARDMORE AVENUE		TELEPHONE:	(562) 804-3603
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 15		CENSUS: 9	DATE:	08/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:27 AM
MET WITH:	Jeniffer Bobadilla - House Manager		TIME VISIT/ INSPECTION COMPLETED:	01:20 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Jennifer Bobadilla (Administrator/Caregiver) the purpose of today’s visit was explained. The facility is licensed to serve 15 residents age 60 and above. (11) may be non-ambulatory and (4) bedridden. Facility is approved for 4 hospice residents.

The facility is located in Bellflower, CA. A tour of the facility includes: 9 bedrooms, 1 staff bedroom, 2 full bathrooms, 1 ½ bathroom, 1 staff bathroom, living room, dining room, kitchen, office area, laundry room, back yard with shaded area, detached garage and a detached shed.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and an Infection Control Plan.
Operational Requirements: The facility maintains a plan of operation with the required Dementia Information and Training. Facility maintains the required liability insurance.
Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. Bathrooms are clean and operational. All residents’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available to the residents. The hot water temperature was tested throughout the facility and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to residents. The last Fire/Emergency Drill was conducted on 6/01/2024. The fire extinguishers were observed and is fully charged. Facility has telephone service on premises. There is a sprinkler system approved by the fire marshal throughout the facility. (Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SIMLA VILLAS INC.	FACILITY NUMBER: 198204374
	VISIT DATE: 08/05/2024

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Staffing: There appears to be sufficient staffing at all times in the facility with at least one CPR trained employee on the premises at all times. Administrator Simla Mehta certificate expires 11/13/2025.
Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, Dementia Training, Hospice Training, and ongoing training. Staff files are maintained at the facility and kept in a locked cabinet within the office area. During todays visit LPA observed 6 staff files with no issues.
Resident Records-Incident Reports: Resident files are kept in a secure location within the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Those on Hospice have the required information and documentation. LPA observed 5 resident files during todays visit with no issues.
Resident Rights-Information: Complaint, Personal Rights and Ombudsman posters were observed in dining area. Residents are provided with telephone at the facility.
Planned Activities: There is an activity schedule posted in the dining area. There are board games, books and daily newspaper readily available for residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Extra food is stored in detached garage.
Incidental Medical & Dental: All medications for residents are kept locked and inaccessible to other residents. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Need: The residents who are on hospice and have a complete hospice care plan maintained at the facility and staff are trained for Hospice Care. All staff files reviewed today also have required training in Dementia and Postural Supports.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit.

Exit interview was held and a copy of the report was provided Administrator Jennifer Bobadilla.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

LIC809 (FAS) - (06/04)

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