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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801382
Report Date: 12/16/2022
Date Signed: 12/16/2022 04:37:41 PM

Document Has Been Signed on 12/16/2022 04:37 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:ANNA'S HOME FOR THE ELDERLYFACILITY NUMBER:
565801382
ADMINISTRATOR:ANNABELLE RAMOSFACILITY TYPE:
740
ADDRESS:3325 ELMORE STREETTELEPHONE:
(805) 285-0385
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 5DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Annabelle RamosTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Required - 1 Year inspection at the facility today. Upon arrival LPA met with staff. Administrator was contacted. At approximately 10:30AM the LPA met with Administrator and explained the reason for the inspection.
Today's annual has an emphasis on infection control practices and procedures.

The LPA, along with Administrator, toured the physical plant areas beginning at 10:45AM:

COMMON SPACES: The common areas were observed. The fire extinguisher was observed to be last serviced on 09/2022. The smoke alarms and carbon monoxide detectors were tested in the common area and observed operational. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies are secured in the locked garage. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: There are three resident bathrooms. Bathrooms had hand soap, paper towels, and signs regarding proper hand washing.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. There is 1 entry access into the facility. Upon entry, the facility has a central entry point for symptom screening. The LPA observed an adequate supply of Personal Protective Equipment (PPE). 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 following was noted: Posting Provider Information Notices (PINs) and educating staff and clients on changing policies and procedures from the Department.


- Arrange N95 fit testing for staff and remind all staff to wear proper face mask.
Visit took longer than expected due to technical difficulties with Inspection tool.
Exit interview conducted. Signatures obtained. A copy of the report was emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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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