<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800045
Report Date: 09/12/2022
Date Signed: 09/12/2022 03:14:55 PM

Document Has Been Signed on 09/12/2022 03:14 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:SIMI VALLEY RESIDENTIAL CARE IIFACILITY NUMBER:
565800045
ADMINISTRATOR:WALTER & MARIA MENDEZFACILITY TYPE:
740
ADDRESS:713 ERRINGER RD.TELEPHONE:
(805) 522-9129
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 0DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Maria MendezTIME COMPLETED:
03:25 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) Teresa Camara arrived at the facility to conduct a required annual visit at 2:18 p.m.

The LPA met with licensee/administrator Maria Mendez and explained the reason for the visit. The licensee stated the facility currently has no residents as the facility is undergoing a remodel.

The LPA toured the physical plant areas inside and outside; there were no residents or staff observed at the facility.

The licensee stated the layout of the facility will not be changing. Bathrooms are being remodeled, new exit doors are being installed, and new flooring throughout the facility is being installed. The ceilings are being repaired due to a leak from the fire suppression system.

Smoke detectors and the carbon monoxide detector were disabled due to the detectors being activated by dust from the remodel.

The licensee would like to retain their license but will not admit residents until the property has been remodeled. Licensee will inform CCL once the remodel is completed so CCL can conduct a physical plant inspection prior to licensee admitting any residents.



Exit interview conducted. A copy of report emailed to licensee.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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 1