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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800680
Report Date: 06/11/2024
Date Signed: 06/11/2024 01:35:40 PM

Document Has Been Signed on 06/11/2024 01:35 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:ST. MARY'S HOME CAREFACILITY NUMBER:
565800680
ADMINISTRATOR/
DIRECTOR:		MARILOU LAIGO-MALLARIFACILITY TYPE:
740
ADDRESS:2474 KNIGHTWOOD CIRCLETELEPHONE:
(805) 584-6322
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 6DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Norma ZandersTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff and explained the reason for the visit. Administrator Marilou Mallari was out of town at the time of the visit, but designated Staff Norma Zanders arrived shortly after. 

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.

LPA began the inspection in the kitchen/food service area at 09:45 a.m. Knives are stored in a locked cabinet in the kitchen. Kitchen appliances observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Cleaning supplies were observed locked and inaccessible under the kitchen sink.

At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 74 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 09/11/2023. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space. 

The backyard has a covered outdoor area equipped with furniture for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted. LPA observed two (2) sheds, both were observed to be inaccessible to residents in care. LPA observed both sheds to store extra furniture, medical equipment and other items for facility use. There is a separate laundry room, which is kept locked at all times. Cleaning supplies and disinfectants are kept locked inside the laundry room. Emergency water was observed in a closet by the entrance.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST. MARY'S HOME CARE
FACILITY NUMBER: 565800680
VISIT DATE: 06/11/2024
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The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four (4) designated resident rooms. The facility has one (1) designated staff bedroom that is maintained locked at all times. The three 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 in each restroom between 105 - 120 degrees Fahrenheit.

Records review began at 10:30am. six (6) resident records were reviewed for the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, appraisals, and current needs and services plan.  All records were in order. LPA reviewed staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification.

Medications review began at 11:45 a.m. The medications are centrally stored and locked in a cabinet inside the kitchen. Medications are labeled and checked for expiration dates. No errors found during medication audit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. The facility has 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 an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Staff and residents were interviewed during the visit.

Exit interview conducted. A copy of the report was provided to designee.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
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