Simi Valley Residential Care III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Administrator Maria Mendez and 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 the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 10:15 a.m. Knives and sharp objects are stored underneath the sink in a locked box. Cabinet was locked and inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. At approx 10:17 a.m. LPA observed staff preparing food. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Office area located near entry way to the backyard. LPA observed facility files securely stored in this area. At the time of the visit, the common area furniture's were observed to be in good condition. A variety of activities were observed stored in the living room. A sufficient supply of clean linen and towels were observed stored in two (2) hallway closets. The facility maintained a comfortable temperature of 71 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The LPA observed six (6) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. At approx. 10:27am, LPA observed staff interacting with residents. The staff room located next to the living room was observed to be inaccessible to residents in care and empty during the time of the visit. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to have an additional fridge to store extra perishable food. LPA also observed a laundry area, laundry supplies securely stored, extra incontinent supplies, linen, PPE , as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. 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. Records review, six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were observed to be in order at this time. Medications review: medications are centrally stored and locked inside a cabinet in the office area. All medications including PRNs were labeled, stored and locked inaccessible to individuals. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during medications review. During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Fire extinguisher was observed fully charged and last serviced 08/14/2025. Carbon monoxide detectors are wired and operational at the time of the visit. Emergency disaster drills conducted quarterly as per regulation; the last one conducted was an earthquake drill on 07/08/2025. LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and facility’s liability insurance Interviews were conducted during the visit. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Sep 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. The last annual inspection conducted at this facility was on 10/23/2023. Upon arrival, there were two (2) staff and five (5) residents present. The LPA was greeted by facility staff who contacted the Licensee Representative via telephone. The Licensee Representative, Maria Mendez arrived during the inspection. Entrance interview conducted. At 10:58am, the LPA along with staff 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. The following was observed: KITCHEN: The LPA inspected the kitchen area at 11:02am. Knives and sharps were observed in a locked box inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food; properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: The living room and dining room areas were furnished appropriately and furniture appeared to be in good condition at the time of the visit. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. Activities for resident use were observed in the living room. There is a working telephone on premises. REPORT CONTINUED ON LIC 809C... REPORT CONTINUED FROM LIC 809... RESTROOMS: There are three (3) restrooms for resident use. Restrooms were observed clean and in sanitary condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Hand washing signs were observed posted in the restrooms. LPA observed trash cans with tight fitting lids in all bathrooms. The hot water temperature was measured in all bathrooms; the first bathroom measured108.6 degrees Fahrenheit at 11:11am; the second bathroom measured 110.4 degrees Fahrenheit at 11:16am; and the third bathroom measured 111.2 degrees Fahrenheit at 11:20am. BEDROOMS: There are six (6) bedrooms for resident use; all of which are designated for single occupancy. All resident rooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens, towels, and washcloths were observed accessible to residents in care. Staff bedroom observed on premises. GARAGE: The garage is maintained inaccessible to residents in care. LPA observed an additional refrigerator with food in good condition. There is a washer and dryer inside the garage. Cleaning supplies, detergents, and toxins were observed locked and inaccessible to residents in care. Facility has an adequate amount of emergency food and water. BACKYARD: The backyard has a covered patio area with adequate furniture for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. LPA observed two (2) self-latching gates for emergency use. There were no bodies of water noted at the time of the visit. RECORDS: LPA reviewed Resident Records at 11:33am and Personnel Records at 12:35pm. REPORT CONTINUED ON LIC 809C... REPORT CONTINUED FROM LIC 809C... Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Records were in order. Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid / CPR training, and the appropriate training. All files were complete. Administrator Certificate is valid until 06/30/2025. During today’s visit, LPA conducted interviews with three (3) residents and one (1) staff member. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. At 11:22am, the smoke detectors and carbon monoxide detector were tested and operational at the time of the visit. Fire extinguisher was observed fully charged with a date of 8/09/2024. Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 10/01/2024. MEDICATIONS: Medications review began at approximately 1:10pm. Medications are stored in locked cabinets adjacent to the living room inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRN authorization letters on file for each resident. Medications appeared to be given as prescribed at the time of the visit. No citations issued at this time. Exit interview conducted. Report was reviewed and a copy issued.the state’s words, verbatim · CDSS document, Oct 15, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian conducted a Required Annual visit to the above facility. LPA was greeted by staff . Licensee Maria Mendez arrived shortly after and reason for the visit was explained. A tour of the physical plant was conducted for compliance with safety, maintenance and operational requirements from 10am-10:45am. The facility has six (6) bedrooms and three (3) bathrooms for residents use. Currently five (5) residents rooms are occupied. There is an additional bedroom designated for staff use. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. Hot water temperature measured at 107 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of (2-day) perishable and (7-day) non-perishable food at the facility. Sharp objects are stored in a lock box in the kitchen. Garage is attached to the home with and entrance off the Kitchen/dining area. Laundry machines and supplies are stored in the garage inaccessible to residents. Surrounding Grounds (Outdoors): There is a shaded area with furniture for outdoor use. Smoke and Carbon Monoxide detector tested and function properly. Fire extingisher last serviced 7/12/2023. Resident file review (11am-12pm): All residents have an annual physician report; Needs and Service plan; admission agreement and all required records per Title 22 on file. Medications/medication documentation reviewed at approximately 12pm-1pm. Centrally stored and medication administration records reviewed. First aid kit is complete. Staff file review (1pm-2pm) Staff have current first aid and required training completed. All required personnel records observed on file. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Oct 23, 2023