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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850167
Report Date: 02/24/2025
Date Signed: 02/24/2025 02:52:55 PM

Document Has Been Signed on 02/24/2025 02:52 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:CASA BLANCA SENIOR LIVINGFACILITY NUMBER:
565850167
ADMINISTRATOR/
DIRECTOR:
VIGIL, MONICAFACILITY TYPE:
740
ADDRESS:5631 EUNICE AVE.TELEPHONE:
(805) 218-0397
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 4DATE:
02/24/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Monica VigilTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a Case Management visit with the purpose of verifying a pending increase in capacity and updating bedridden for the facility. Upon arrival, the LPA was greeted by the Administrator, Monica Vigil and the reason for the visit was explained. Entrance interview conducted.

A capacity change and bedridden update was requested for the facility to increase capacity from 4 residents to 6 and updating bedroom #4 to be bedridden. The fire clearance (STD850) was approved on 02/20/2025 for capacity of 5 non-ambulatory residents in bedrooms #1 - #5 and 1 bedridden resident in bedroom #4 only.

During today’s visit, the LPA, along with the Administrator, toured the facility. The LPA observed that Bedroom #3, which was previously a staff room, is now set up as a shared resident bedroom. For the NOC shift, awake night staff will be present. Additionally, Bedroom #4 has a direct exit to the outside. Both the main hallway leading to the resident bedrooms and Bedroom #4 were observed to be equipped with fire doors. Physical plant is consistent with the submitted facility sketch/floor plan.

No physical plant or health and safety concerns were noted during today's visit.

No citations issued. Exit interview conducted. A copy of today's report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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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