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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800417
Report Date: 10/23/2023
Date Signed: 10/23/2023 06:20:17 PM

Document Has Been Signed on 10/23/2023 06:20 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 IVFACILITY NUMBER:
565800417
ADMINISTRATOR:MARIA MENDEZFACILITY TYPE:
740
ADDRESS:2378 E. KENTFIELD STREETTELEPHONE:
(805) 583-3182
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 3DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maria MendezTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a Required Annual visit. LPA met with Licensee/Administrator Maria Mendez and staff. Reason for the visit was explained.

Beginning at 2:45pm, LPA with the assistance of the Licensee took a tour of the physical plant. Required postings were observed in the living room and hallway. Dual smoke and carbon monoxide detectors are hardwired and was functioning properly during the visit. Fire extinguisher observed charged/serviced 7/12/24. Bedrooms: There are four bedrooms designated for residents' use. All bedrooms were properly furnished and had sufficient lighting. There was appropriate bedding and linens. There is a staff room that is kept locked when not in use. Bathrooms: There were two bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 106.5*F degrees Common Areas: These included the living room and dining area which were observed properly furnished. Auditory alarms on all exit doors were on and functional at the time of the visit. Medications were locked in a cabinet in the office/kitchen area. Surrounding Grounds: Entry/exits were free of obstruction. The laundry area is in the garage. Cleaning supplies and detergents are stored in locked cabinets in the garage. Kitchen: The kitchen appliances and fixtures observed functional. Observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food at the facility; properly stored. Knives observed stored in a locked drawer in the kitchen. Resident Files: All resident files reviewed at 3pm. Resident files included a current medical assessments, appraisals, consent forms, and admission agreements. Staff
Files: Reviewed at 3:45pm. Files included current first aid certifications and training documentation. All staff have criminal record clearance and are associated to this facility. Medications: Reviewed at 4pm. Files included medication administration records and centrally stored medication logs. Medications and logs were consistent. First aid kit observed complete. PPE supply observed sufficient for at least three weeks.

No deficiencies will be cited at today's visit. Exit interview conducted, copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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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