Simi Valley Residential Care IV

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 Giovani Fulgentes 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. 09:45 a.m. Knives and sharp objects are stored in a locked drawer to the right of the stove. Kitchen appliances were observed to be in operable condition. At approx 09:50 a.m. LPA observed staff cleaning. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Office area located next to the kitchen. LPA observed facility files and resident medication securely stored in this area. 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 gates with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit. The LPA observed four (4) 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. 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. A sufficient supply of clean linen and towels were observed stored in two (2) hallway closets. Resident toiletries were observed stored inaccessible in a closet next to the staff room. At approx. 10:17am, LPA observed staff preparing food. At the time of the visit, the common area furniture's were observed to be in good condition. The facility maintained a comfortable temperature of 70 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at 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. Records review, four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Four (4) 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 07/11/2025 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, Oct 2, 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. Upon arrival, the LPA was greeted by facility staff who contacted the Administrator via telephone. At this time, the reason for the visit was explained. The Administrators, Maria Mendez and Jennifer Fulgentes arrived during the inspection. Entrance interview conducted. The 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. The following was observed: KITCHEN: The LPA inspected the kitchen/food service. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged 08/05/2024. The LPA observed required postings throughout the common space. Activities were observed in the common areas. LPA observed a locked closet by the main hallway with personal hygiene items for resident use. RESTROOMS: The two (2) 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; the first bathroom measured at 107.2 degrees Fahrenheit at 9:33am; and the second bathroom measured at 106.7 degrees Fahrenheit at 9:37am. Report Continued on LIC 809C... Report Continued from LIC 809... BEDROOMS: There are five (5) total bedrooms in the facility: one (1) bedroom is designated as a shared room, three (3) bedrooms are designated as private resident rooms; and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. GARAGE/BACKYARD: There is a washer and dryer inside the garage. Laundry detergent and cleaning supplies were observed in a locked cabinet. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit. RECORDS: LPA did not conduct record review as there is currently no residents residing at the facility at this time. MEDICATIONS: LPA did not conduct medication review as there is currently no residents residing at the facility at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 8, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian conducted a Required Annual visit. LPA met with Licensee/Administrator Maria Mendez and staff. Reason for the visit was explained. Beginning at 2:45pm, LPA with the assistance of the Licensee took a tour of the physical plant. Required postings were observed in the living room and hallway. Dual smoke and carbon monoxide detectors are hardwired and was functioning properly during the visit. Fire extinguisher observed charged/serviced 7/12/24. Bedrooms: There are four bedrooms designated for residents' use. All bedrooms were properly furnished and had sufficient lighting. There was appropriate bedding and linens. There is a staff room that is kept locked when not in use. Bathrooms: There were two bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 106.5*F degrees Common Areas: These included the living room and dining area which were observed properly furnished. Auditory alarms on all exit doors were on and functional at the time of the visit. Medications were locked in a cabinet in the office/kitchen area. Surrounding Grounds: Entry/exits were free of obstruction. The laundry area is in the garage. Cleaning supplies and detergents are stored in locked cabinets in the garage. Kitchen: The kitchen appliances and fixtures observed functional. Observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food at the facility; properly stored. Knives observed stored in a locked drawer in the kitchen. Resident Files: All resident files reviewed at 3pm. Resident files included a current medical assessments, appraisals, consent forms, and admission agreements. Staff Files: Reviewed at 3:45pm. Files included current first aid certifications and training documentation. All staff have criminal record clearance and are associated to this facility. Medications: Reviewed at 4pm. Files included medication administration records and centrally stored medication logs. Medications and logs were consistent. First aid kit observed complete. PPE supply observed sufficient for at least three weeks. No deficiencies will be cited at today's visit. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Oct 23, 2023