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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609938
Report Date: 12/23/2021
Date Signed: 12/23/2021 03:41:03 PM

Document Has Been Signed on 12/23/2021 03:41 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:RESIDENTIAL FIRST CARE, LLCFACILITY NUMBER:
567609938
ADMINISTRATOR:MEDINA, LIDIAFACILITY TYPE:
740
ADDRESS:6109 VERA STTELEPHONE:
(805) 842-1679
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 3DATE:
12/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Lidia MedinaTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Martha Guzman Chavez arrived at the facility unannounced to conduct a required annual visit at 1:05 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA was scanned and greeted at the door by staff Jackie. The LPA met with Administrator Lidia Medina shortly after and explained the reason for the visit. Entrance interview.

The LPA toured the physical plant areas with the Administrator inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed knives and sharps to be locked in a drawer next to the oven. Cleaning supplies were locked in a cabinet under the sink. BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. Bathrooms were measure for hot water, first bathroom measured at 105.2 degrees Fahrenheit and the second bathroom measured at 105.8 degrees Fahrenheit. COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The main facility temperature was observed at 75 degrees Fahrenheit. The LPA observed medications to be locked and inaccessible in the hallway closet. Required postings were observed in the entryway. The LPA observed a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit. GARAGE: The garage is locked and inaccessible to residents in care. Inside the garage is the laundry room. The LPA observed an additional refrigerator and freezer in the garage. Emergency food and water was also observed with additional food. Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: RESIDENTIAL FIRST CARE, LLC
FACILITY NUMBER: 567609938
VISIT DATE: 12/23/2021
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Continued from LIC 809...

The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) in the garage and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. All staff and residents are vaccinated. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC809 (FAS) - (06/04)
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