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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850266
Report Date: 09/11/2024
Date Signed: 09/11/2024 04:06:16 PM

Document Has Been Signed on 09/11/2024 04:06 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:ALTA VISTA SIMI #2 LLCFACILITY NUMBER:
565850266
ADMINISTRATOR/
DIRECTOR:		REDLIN, VICTORIA N.FACILITY TYPE:
740
ADDRESS:2942 ROSETTE ST.TELEPHONE:
(805) 208-2345
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 6DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Emiliano C SiapnoTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit.  Administrator Emiliano C Siapno arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.
LPA inspected the kitchen/food service area at approx. 12:05 p.m.  Knives and sharp objects are stored in a locked box in a locked drawer to the right of the stove. No cleaning supplies were observed stored in the kitchen area.  Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Office area located in the kitchen.
At the time of the visit, the common area furniture's were observed to be in good condition. Medications and a sufficient supply of PPE and toiletries were observed stored inaccessible to residents in care in a closet at the entry way. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last purchased in July of 2024.
The LPA observed four (4)  resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The  resident restrooms 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. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. LPA observed hallway cabinets to store various electronic equipment, flashlights and other supplies for emergency use.
All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas.
There is an attached garage observed inaccessible to residents in care. LPA observed garage to store an additional fridge to store extra perishable food. LPA also observed a laundry area, a sufficient supply of clean linen and towels, laundry supplies securely stored, extra incontinent supplies,  PPE , canned goods, emergency food supply as well as additional furniture and medical equipment for facility use.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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: ALTA VISTA SIMI #2 LLC
FACILITY NUMBER: 565850266
VISIT DATE: 09/11/2024
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Continued from 809

The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. There were no bodies of water over 3ft noted at the time of the visit. LPA observed a storage shed  behind a locked gate that stored extra furniture and equipment for facility use. LPA also observed a small tool shed behind the locked gate that stored various gardening tools.

Records review began at approx. 12:30 p.m. , six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Three  (3) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time . Last emergency disaster drill was conducted on August 5, 2024

Medications review began at approx. 01:30 p.m. All medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time.

Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. 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 an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Interviews were conducted during the visit.

Exit interview conducted. A copy of the report was provided to the Administrator
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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