565801382-12-23-2024-29-AS-MARO-DC8U5P-20241223141704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801382
Report Date: 12/23/2024
Date Signed: 12/23/2024 02:18:01 PM

Document Has Been Signed on 12/23/2024 02:18 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 ELDERLY		FACILITY NUMBER:	565801382
ADMINISTRATOR/ DIRECTOR:	ANNABELLE RAMOS		FACILITY TYPE:	740
ADDRESS:	3325 ELMORE STREET		TELEPHONE:	(805) 285-0385
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6		CENSUS: 4	DATE:	12/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Annabelle Ramos		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:30am. Upon arrival, there were two (2) staff and four (4) residents present. The LPA was greeted by facility staff who contacted the Administrator via telephone. The Administrator, Annabelle Ramos arrived during the inspection. Entrance interview conducted.

Starting at 10:40am, the LPA along with staff 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. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Knives and sharps were observed locked and inaccessible in a kitchen cabinet. At 10:48am, the hot water temperature was measured in the kitchen sink, and it measured at 108.5 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be fully charged with a date of 05/08/2024. Required postings were observed throughout the common space. Activities were observed accessible to residents in care. There is a working telephone on premises. The LPA observed a closet in the hallway with additional clean linens and towels. Working auditory alarms were observed at the time of the visit.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

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: ANNA'S HOME FOR THE ELDERLY	FACILITY NUMBER: 565801382
	VISIT DATE: 12/23/2024

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Report Continued from LIC 809...

RESTROOMS: There are three (3) restrooms for resident use. Bathrooms 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. Starting at 9:42am, the hot water temperature was measured in all bathrooms, and they measured between 107.5 and 110.8 degrees Fahrenheit.

BEDROOMS: There are four (4) bedrooms for resident use. Two (2) bedrooms are designated as single occupancy, and two (2) bedrooms are designated for double occupancy. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff bedroom on premises.

GARAGE: The garage was locked and inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water. Washer and dryer were observed inside the garage. Additional cleaning supplies are kept in the garage locked and inaccessible to residents in care.

BACKYARD: The backyard has a covered patio area with patio furniture for resident use. All passageways were observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms. No bodies of water noted at the time of the visit.

RECORDS: The LPA reviewed Resident Records at 10:20am and Personnel Records at 11:05am.

Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

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: ANNA'S HOME FOR THE ELDERLY	FACILITY NUMBER: 565801382
	VISIT DATE: 12/23/2024

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Report Continued from LIC 809C...

Five (5) personnel files including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order. Administrator’s Certificate is valid until 12/01/2025.

The LPA conducted interviews with two (2) staff during the inspection.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills conducted quarterly as per regulation; last one conducted on 12/17/2024.

MEDICATIONS: Medications review began at approximately 12:20pm. Medications are kept in a locked cabinet in the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record. Medications appeared to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

LIC809 (FAS) - (06/04)

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