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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609938
Report Date: 12/23/2022
Date Signed: 12/28/2022 09:58:19 AM

Document Has Been Signed on 12/28/2022 09:58 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: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:
12/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Edward N. - StaffTIME COMPLETED:
10:07 AM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a Required Annual visit. This annual had a specific emphasis on infection control practices and procedures.

Upon arrival LPA explained the reason for the visit. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility can 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 COVID-19. The Administrator ensures that staff and residents are provided with updates regarding changing policies and procedures from the Department; including facility’s Mitigation and Infection Control Plan. The facility has three (3) positive cases of COVID-19 at this time. Tthe facility’s policies and procedures as it pertains to infection control will be followed. Physical plant toured with staff: KITCHEN: Knives and chemicals are stored inaccessible. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: LPA observed signs posted on the bedroom door of the positive residents door. RESTROOMS: Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed appropriate signage in the bathrooms promoting hand hygiene. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings on the bulletin board. In addition, the LPA observed postings throughout the facility that promote understanding symptoms of COVID-19, and best practices.

Following recommendations were made: - Set PPE supplies in the hallway closer to to positive resident rooms. Exit interview conducted. A copy of report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2022
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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