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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801056
Report Date: 08/06/2021
Date Signed: 08/06/2021 03:56:10 PM

Document Has Been Signed on 08/06/2021 03:56 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:MILLENNIUM CARE IIFACILITY NUMBER:
565801056
ADMINISTRATOR:IRIS VAN KRALINGENFACILITY TYPE:
740
ADDRESS:5694 FEARING STREETTELEPHONE:
(805) 527-7798
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 6DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Iris Van KralingenTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 2:25pm. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Iris Van Kralingen and explained the reason for the visit.

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.

KITCHEN: Knives and chemicals are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

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

RESTROOMS: Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed appropriate signage in all bathrooms promoting proper hand hygiene.

COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings on the bulletin board. In addition, the LPA observed postings throughout the facility that promote cough etiquette, understanding symptoms of COVID-19, and best practices of protecting oneself from COVID-19.

The backyard has a covered outdoor area equipped with furniture for resident use. The property is completely fenced with a self-latching mechanism. There is a completely fenced swimming pool, which is kept locked and inaccessible to residents. The LPA observed that the facility a sufficient supply of Personal Protection Equipment (PPE) and a surplus of incontinent supplies in the garage.


CONT 809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2021
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: MILLENNIUM CARE II
FACILITY NUMBER: 565801056
VISIT DATE: 08/06/2021
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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 facility has an adequate supply of Personal Protection Equipment (PPE) and the facility can 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 Administrator ensures that staff and residents are provided with updates regarding changing policies and procedures from the Department. The LPA also reviewed the facility’s Mitigation Plan during today’s visit. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC809 (FAS) - (06/04)
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