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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850352
Report Date: 06/30/2025
Date Signed: 06/30/2025 02:47:14 PM

Document Has Been Signed on 06/30/2025 02:47 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:THESSALONICA HOME CAREFACILITY NUMBER:
565850352
ADMINISTRATOR/
DIRECTOR:		TAPEL, NIDAFACILITY TYPE:
740
ADDRESS:5629 E PITTMAN STTELEPHONE:
(909) 509-1073
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 5DATE:
06/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Natalia DelaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo 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. The Administrator was unavailable during today’s visit, but designated staff to sign report. Entrance interview conducted.

Starting at 09:50am, 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 at 10:05am. Knives and sharps were observed in a locked drawer inaccessible to residents in care. Cleaning supplies were kept locked and inaccessible under the kitchen sink at the time of the visit. 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. Hot water temperature was checked in kitchen faucet, and it measured 113.00 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 06/15/2025.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/30/2025 02:47 PM - It Cannot Be Edited


Created By: Martha Arroyo On 06/30/2025 at 02:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: THESSALONICA HOME CARE
FACILITY NUMBER: 565850352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as none of the staff on premises have current first aid / cpr, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2025
Plan of Correction
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The staff will complete first aid / cpr certification today and submit proof to CCL no later than POC due date.
Type B
Section Cited
CCR
87613(a)(2)(B)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as LPA was unable to determine hours completed by each staff, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The staff will have 20 hours training completed in the next 30 days and submit proof to CCL no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


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: THESSALONICA HOME CARE
FACILITY NUMBER: 565850352
VISIT DATE: 06/30/2025
NARRATIVE
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Report Continued from LIC 809...

Required postings were observed throughout the common space. The LPA observed a fireplace adequately covered at the time of the visit. Activities were observed in the living room. There is a working telephone on premises. The LPA observed a closet in the hallway with additional clean linens and towels. Auditory alarms were observed at the time of the visit. The LPA observed an adequate supply of emergency food and water. At 10:12am, the smoke detectors and fire door were tested and operational at the time of the visit. No obstructions or hazards observed inside or out.

LAUNDRY ROOM: There is a laundry room with a washer and dryer. Laundry detergents and toxins were observed locked and inaccessible at the time of the visit.

RESTROOMS: There are two (2) restrooms for resident use. One (1) bathroom is located by the main hallway and the second bathroom is located inside bedroom #2. 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. Personal hygiene items were also observed locked under the sink at the time of the visit. Starting at 09:55am, the hot water temperature was measured in bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit at the time of the inspection.

BEDROOMS: There are four (4) bedrooms for resident use. Two (2) bedrooms are designated for double occupancy and two (2) bedrooms are designated for private / single occupancy. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. Bedrooms #1, #2, and #3 were observed to have access to the outside perimeter. The LPA observed a staff room on premises which was inaccessible to residents in care at the time of the inspection.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
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: THESSALONICA HOME CARE
FACILITY NUMBER: 565850352
VISIT DATE: 06/30/2025
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Report Continued from LIC 809C...

OUTDOORS / BACKYARD: The backyard was observed with a shaded area with appropriate furniture for resident use. There are two (2) side gates that self-latch. All passageways were observed to be clear of any obstructions. No bodies of water noted at the time of the visit.

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

Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, preplacement appraisals, consent for treatment form, and current needs and services plan.

Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. During record review, it was revealed that facility does not have a staff training binder; therefore, LPA was unable to verify yearly training. Additionally, staff on premises do not have current first aid/cpr training. Staff stated they will complete training by today.

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; most current drill conducted on 05/03/2025.

MEDICATIONS: Medications review began at approximately 12:15pm. Medications are centrally stored in a locked closet by the main hallway. First Aid Kit and manual were observed and complete at time of the visit. Medications appeared to be given as prescribed at the time of the visit.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC809 (FAS) - (06/04)
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