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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800421
Report Date: 01/19/2023
Date Signed: 01/20/2023 08:43:58 AM

Document Has Been Signed on 01/20/2023 08:43 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:MILLENIUM CAREFACILITY NUMBER:
565800421
ADMINISTRATOR:MAYA X. DAVIDSZFACILITY TYPE:
740
ADDRESS:1555 HILGARD AVENUETELEPHONE:
(805) 526-4440
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 5DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Iris VankralingenTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required Annual visit at 9:44 a.m. This annual had a specific emphasis on infection control practices and procedures. Upon arrival the LPA met with two (2) staff. The LPA met with Administrator Iris Vankraligen at 10:02 a.m., and explained the reason for the visit.

The LPA and the administrator toured the physical plant areas inside and outside, with Iris Vankralingen at 10:14 a.m., to ensure there are no health and safety hazards.


BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.


RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom.


KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Kitchen cleaning supplies were observed to be properly stored, and locked at time of visit.

Continued on LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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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: MILLENIUM CARE
FACILITY NUMBER: 565800421
VISIT DATE: 01/19/2023
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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture were observed to be in good condition. The LPA observed required postings on the wall near the front entry way. Two (2) fire extinguishers were observed to be fully charged with a service date of 02/2022. The facility’s laundry area was properly secured with a padlock.


BACKYARD: The backyard has a covered outdoor area equipped with furniture for residents' use. There were no bodies of water noted. The facility garage is attached to the facility, and is currently being utilized as storage.


INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

Exit interview was conducted with the Administrator. A copy of the report was issued

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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