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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610022
Report Date: 08/17/2021
Date Signed: 08/17/2021 11:17:26 AM

Document Has Been Signed on 08/17/2021 11:17 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:APPLETON HOMESFACILITY NUMBER:
567610022
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:1149 APPLETON RDTELEPHONE:
(747) 237-0417
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Myline OlivasTIME COMPLETED:
11:16 AM
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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced visit to Appleton Homes to conduct a Required 1-Year Annual Inspection with focus on Infection Control. No previous Annual has been conducted since they were pre-licensed on 9-01-2020. LPA was greeted and screened at the door by staff Albert Salunga. Administrator Myline Olivas arrived at the facility at 9:12am and was explained the reason for the visit.

LPA 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. LPA along with Administrator Myline, initiated a tour at 9:12am and the following was observed:

There is a central entry point designated for universal screening by the entrance. Smoke detectors and Carbon Monoxide detector were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged. First-Aid Kit was observed by the entrance of the facility. Medications are in the dining room area in a locked cabinet. Main temperature displayed by hallway and read at 77 degrees Fahrenheit for the facility.



OUTDOOR SPACE: LPA observed the backyard to have a covered outdoor area with a tables and chairs for resident use. There are two (2) gates on each side of the house that have a single latch and always remains unlocked.

KITCHEN: LPA observed the kitchen/dining area to be clean. Knives are stored in a locked cabinet in the kitchen by the oven. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

Continued on LIC 809c

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 08/17/2021
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Continued from LIC 809

BEDROOMS: LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and a table lamp.

RESTROOMS: LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. Water temperature was checked in two (2) resident bathrooms and are in compliance at 105.8 degrees Fahrenheit for bathroom #1- and 107.6 degrees Fahrenheit for bathroom #2.

LPA observed at least a 30-day supply of Personal Protection Equipment (PPE). The facility cleans the common areas at least twice daily. There are signs posted throughout the facility showing cough/sneeze etiquette and how to properly wash hands. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. LPA observed CDSS PINs posted by the entrance accessible to both residents and visitors. LPA encouraged Administrator to have staff fit tested for N95 masks due to rising numbers in positive cases.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Exit interview conducted. A copy of the report and appeal rights were provided via email.

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

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
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