565850266-9-30-2022-29-AS-TCAA-CJRLK7-20220930084900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850266
Report Date: 09/27/2022
Date Signed: 09/30/2022 08:49:47 AM

Document Has Been Signed on 09/30/2022 08:49 AM - 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:	ALTA VISTA SIMI #2 LLC		FACILITY NUMBER:	565850266
ADMINISTRATOR:	REDLIN, VICTORIA N.		FACILITY TYPE:	740
ADDRESS:	2942 ROSETTE ST.		TELEPHONE:	(805) 208-2345
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 0	DATE:	09/27/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Victoria Redlin		TIME COMPLETED:	01:42 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Teresa Camara conducted a pre-licensing visit to the above noted facility. The LPA met with applicant Victoria Redlin. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver for six (6) has been requested. The facility is one-story. At 11:12 a.m. a physical plant tour was conducted inside and out. An approved fire clearance was received for six bedridden residents. The facility has two (2) double-occupancy resident bedrooms and two (2) single occupancy resident bedrooms. Bedroom number one (1) has a direct exit with a ramp to the outside; the other bedrooms do not have an exit to outside. All resident rooms are set up with beds, night stands, lamps, chairs, closet space, closet organizers and dressers for storage. The beds are furnished with either platform bed base, spring bed base or box spring with comfortable mattresses and clean linen; which includes, a mattress cover, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is no designated staff room, therefore awake night staff is required. All rooms were free of odors. All window screens were clean and maintained in good repair. There are three full bathrooms in the house. The two primary resident bathrooms each have a roll-in shower with non-skid mats with grab bars. The hot water temperature was tested and found to be within the range of 105F and 120F; with an average of 112.3*F. The facility smoke alarm system is hard wired. The smoke detectors and carbon monoxide detectors were tested and functioned properly during the time of visit. The facility also has a fire suppression sprinkler system. There were three fire extinguishers located in or near the kitchen all purchased in September 2022. Resident and staff records are stored in a locked cabinet in the garage. Medications are centrally stored in a locked closet at the entryway. The first aid supplies were complete, including a thermometer and a current version of a first aid manual which were also stored in the medication closet.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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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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: ALTA VISTA SIMI #2 LLC	FACILITY NUMBER: 565850266
	VISIT DATE: 09/27/2022

NARRATIVE

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Kitchen knives are stored in a locked box in the kitchen. Stove burners are rendered inaccessible to the residents by removing the knobs when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 38*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. The trash can was stored in a cabinet under the sink. Kitchen, laundry and house cleaning supplies are stored in the locked garage. No flies or other vermin were observed. The laundry area is in the locked garage along with extra towels and bed linens as well as hygiene and PPE supplies.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is no fireplace inside the home. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility is awaiting installation of a telephone; a cell phone is being used in the meantime. The emergency exiting plans/sketch are posted near the front door. The emergency telephone numbers are posted in the living room along with other required postings.

The exterior passageways were clean and clear of any obstructions. There is a patio area with a table, chairs and shade cover. The side gate is self-latching. There is a locked storage shed behind a locked gate. There are no bodies of water on the premise.

LPA conducted a Component III review with the applicant and co-administrator Emil Siapno. The application is ready for completion. Exit interview conducted and report emailed to the applicant.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC809 (FAS) - (06/04)

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