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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850067
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:03:53 PM

Document Has Been Signed on 01/23/2025 03:03 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:VISTA AT SIMI VALLEYFACILITY NUMBER:
565850067
ADMINISTRATOR/
DIRECTOR:
LEWIS, MADISONFACILITY TYPE:
740
ADDRESS:1236 ERRINGER ROADTELEPHONE:
(805) 351-8802
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 130CENSUS: 93DATE:
01/23/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Madison LewisTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with Administrator Madison Lewis and explained the reason for the visit.  LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations.
 
At approx 01:30pm LPA conducted a walk through of the facility. The furniture in the common areas were observed to be clean and in good condition. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space.  Stairwells were observed to have emergency evacuation chairs.  There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. LPAs observed four (4) randomly selected  resident bedrooms in memory care and  assisted living. All resident bedrooms were furnished appropriately and had sufficient lighting.  All resident restrooms appeared 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  between 105 - 120 degrees Fahrenheit. Fire extinguishers were observed fully charged and last serviced on August 13, 2024. The facility has a sufficient supply of perishable and non-perishable food. No obstructions or hazards were observed inside or out.
 
LPA reviewed Resident Records at 02:00 p.m. Five (5) 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 records were observed in order at this time.
 
No immediate health and safety concerns observed during the visit. Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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