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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850605
Report Date: 01/29/2025
Date Signed: 01/29/2025 11:25:50 AM

Document Has Been Signed on 01/29/2025 11:25 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:REGAL RESIDENCEFACILITY NUMBER:
565850605
ADMINISTRATOR/
DIRECTOR:		BRODT, DONALDFACILITY TYPE:
740
ADDRESS:3011 N. PEORIA AVETELEPHONE:
(805) 587-2992
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 0DATE:
01/29/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Donald BrodtTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Martha Arroyo conducted a pre-licensing visit to this property at 9:00am and met with Applicant Representative, Donald Brodt. Component II was completed on 01/21/2025. During today's visit, LPA completed Component III with the Applicant Representative.

The applicant has obtained a fire clearance on 12/18/2024 for six (6) bedridden residents approved for bedrooms #1 - #5. The Applicant Representative submitted a hospice waiver request for 6 (six) residents which was approved on 01/19/2025. A dementia care program will be in place.

The facility is a single-story home in the Simi Valley area, which will be licensed as a Residential Care Facility for the Elderly (RCFE). Currently, there are no residents residing in the facility. The facility consists of five (5) bedroom and three (3) bathrooms. There will be a staff room on premises. Main hallway leading to resident bedrooms was observed to be equipped with fire door.

Beginning at 9:07am, the LPA along with the Applicant Representative conducted a physical plant tour to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. THe LPA also inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was observed:

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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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: REGAL RESIDENCE
FACILITY NUMBER: 565850605
VISIT DATE: 01/29/2025
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Report Continued from LIC 809...

The LPA toured the kitchen area at 9:08am, and all equipment appeared to be clean and in good repair. Kitchen knives will be stored in a locked drawer. The kitchen has a sufficient supply of plates, cups, cookware and utensils.

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There is a fireplace present with a fireplace screen for safety at the time of visit. Night-lights were present in the main hallway and resident bathrooms. Functioning auditory alarms observed at the time of the visit. The facility has a sufficient supply of emergency food and water.

Medications and facility records will be stored and locked in a cabinet adjacent to the kitchen. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Flashlights were observed in case of an emergency.

Garage: The garage is attached to the house and will be locked at all times.

The facility has a laundry room. All detergents, disinfectants, and cleaning supplies will be stored in a locked cabinet above the washer and dryer. There will be no firearms/ammunition stored on the property.

At 9:24am, all hard-wired smoke alarms and carbon monoxide detector were tested and function properly. The LPA observed a new fire extinguisher with a purchase date of 12/14/2024.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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: REGAL RESIDENCE
FACILITY NUMBER: 565850605
VISIT DATE: 01/29/2025
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Report Continued from LIC 809C...

There are five (5) bedrooms for resident use; four (4) bedrooms are designated for single occupancy and one (1) bedroom is designated for double occupancy. Bedrooms #1, #2, #4, and #5 will be private resident rooms and bedroom #3 will be a shared resident bedroom. Bedrooms # 3 and #5 have a direct exit to the outside. Each bedroom is equipped with a bed which included a mattress and bedding. Bedrooms have sufficient lighting. The facility has two (2) bathrooms for resident use, which are located by the main hallway and inside bedroom #3. The staff bathroom is located by the laundry room. Resident bathrooms contained appropriate non-skid surfaces and grab bars. Bathrooms have sufficient paper products. Hot water temperature was measured in both bathrooms and measured within the range of 105 and 120 degrees Fahrenheit.

The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.

The exterior passageways were clean and clear of any obstructions. There is one (1) self-latching gate for emergency use. There is a pool which was fully enclosed at the time of the visit. Physical plant is consistent with the submitted facility sketch/floor plan.

The physical plant of this facility location is in compliance with Title 22 regulations at this time.

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.

Exit interview conducted. A copy of the report was reviewed and provided to Applicant Representative Daniel Brodt.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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