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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800417
Report Date: 10/08/2024
Date Signed: 10/08/2024 10:21:28 AM

Document Has Been Signed on 10/08/2024 10:21 AM - 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/
DIRECTOR:		MARIA MENDEZFACILITY TYPE:
740
ADDRESS:2378 E. KENTFIELD STREETTELEPHONE:
(805) 583-3182
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 0DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jennifer Fulgentes / Maria MendezTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, the LPA was greeted by facility staff who contacted the Administrator via telephone. At this time, the reason for the visit was explained. The Administrators, Maria Mendez and Jennifer Fulgentes arrived during the inspection. Entrance interview conducted.

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

KITCHEN: The LPA inspected the kitchen/food service. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged 08/05/2024. The LPA observed required postings throughout the common space. Activities were observed in the common areas. LPA observed a locked closet by the main hallway with personal hygiene items for resident use.

RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 107.2 degrees Fahrenheit at 9:33am; and the second bathroom measured at 106.7 degrees Fahrenheit at 9:37am.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SIMI VALLEY RESIDENTIAL CARE IV
FACILITY NUMBER: 565800417
VISIT DATE: 10/08/2024
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Report Continued from LIC 809...

BEDROOMS: There are five (5) total bedrooms in the facility: one (1) bedroom is designated as a shared room, three (3) bedrooms are designated as private resident rooms; and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting.

GARAGE/BACKYARD: There is a washer and dryer inside the garage. Laundry detergent and cleaning supplies were observed in a locked cabinet. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit.



RECORDS: LPA did not conduct record review as there is currently no residents residing at the facility at this time.

MEDICATIONS: LPA did not conduct medication review as there is currently no residents residing at the facility at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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