565850509-12-10-2024-29-AS-BBAI-DBTTB7-20241210133439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850509
Report Date: 12/10/2024
Date Signed: 12/10/2024 01:35:21 PM

Document Has Been Signed on 12/10/2024 01:35 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:	GREEN VALLEY HOME CARE		FACILITY NUMBER:	565850509
ADMINISTRATOR/ DIRECTOR:	ZANDERS, VANNESSA		FACILITY TYPE:	740
ADDRESS:	2651 BANCOCK ST		TELEPHONE:	(805) 579-0040
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 5	DATE:	12/10/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Norma Zanders		TIME VISIT/ INSPECTION COMPLETED:	02:00 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) Brian Balisi conducted a pre-licensing visit to the above noted facility. The LPA met with applicants Norma and Vanessa Zanders. This is a change of ownership. The facility is currently operating as Green Valley Home Care #565800073 . A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The current capacity is for six (6) residents, the facility has (5) residents in care. The fire clearance was cleared for (6) non-ambulatory. The facility is one story. At approx. 11:15 am, a physical plant tour was conducted inside and out. The facility has five (5) resident bedrooms. Bedroom # 3 is the only shared room. Bedroom #2 and #4 have direct exits to the outside. There are no fire sprinklers in the facility. There are no fire doors in the facility. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is a staff room located next to the kitchen. LPA observed it to be empty at this time. For NOC , there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. There are two (2) bathrooms total. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Resident and staff records are to be stored inaccessible in the office area, located in the living room next to the entrance. Medications are centrally stored and locked in a cabinet adjacent to the kitchen.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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: GREEN VALLEY HOME CARE	FACILITY NUMBER: 565850509
	VISIT DATE: 12/10/2024

NARRATIVE

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The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was observed stored inaccessible in the hallway closet as well.

Kitchen knives are stored inaccessible underneath the sink. 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 40*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 at the time of the visit. Trash cans had tight fitting lids. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television in the living room. Entertainment equipment, games and/or activity supplies was observed on a shelf in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non private bathrooms. There is a fireplace in the facility that is secured and properly screened.

The facility has emergency exit signs . 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 smoke alarm system is hard-wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Fire extinguishers were observed fully charged and serviced in July 2024.

The laundry area is located next to bedroom #3 and is inaccessible to residents in care. LPA also observed personal hygiene items properly stored in this area as well. Cleaning supplies and toxins were observed stored here and the room will be inaccessible to residents in care. The garage is attached to the home and only accessible from the outside. LPA observed extra facility supplies emergency food supplies, extra non-perishable food, and facility equipment, tools, PPE and décor

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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: GREEN VALLEY HOME CARE	FACILITY NUMBER: 565850509
	VISIT DATE: 12/10/2024

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There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted at the entrance, in the main hallway and in the bedrooms. The emergency telephone numbers are posted on the bulletin board near the front entry way. Other required postings are posted on the bulletin board as well.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the rear of the home. LPA observed appropriate furniture for outdoor use. The outside area was observed to be large enough to conduct outdoor activities. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit.

Medications review began at approx 1:00 p.m. The medications are centrally stored. Medications are labeled and checked for expiration dates. No errors found during medication audit.

The entire property is not fenced. There is no body of water observed at this time.

Component III was conducted in conjunction with the visit.

No corrections required on a pre-licensing visit at this time. Exit interview conducted. Report issued and provided to Licensee.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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