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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801056
Report Date: 09/01/2022
Date Signed: 09/01/2022 07:59:42 PM

Document Has Been Signed on 09/01/2022 07:59 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: 5DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Iris Van KralingenTIME COMPLETED:
11:51 AM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a Required Annual visit. This annual had a specific emphasis on infection control practices and procedures.
Upon arrival LPA met with Administrator Iris Van Kralingen and explained the reason for the visit.
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.
LPA and Administrator 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. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: LPA observed the 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. LPA observed signage in one bathrooms promoting 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 understanding symptoms of COVID-19, and best practices of protecting oneself from COVID-19. BACKYARD: Covered outdoor area equipped with furniture for resident use. Property has a pool complete fenced and kept locked inaccessible to residents.
Following recommendations were made: -Appropriate signage to remind staff/client of cough etiquette and hand hygiene, etc. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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