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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191204625
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:48:16 AM

Document Has Been Signed on 11/22/2021 10:48 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SPRING MEADOWS HOMEFACILITY NUMBER:
191204625
ADMINISTRATOR:VON BUCK, EARL A.FACILITY TYPE:
735
ADDRESS:43758 NORTH HARDWOODTELEPHONE:
(661) 942-2010
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 5DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Diana RaineyTIME COMPLETED:
10:45 AM
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LPA Spaeth conducted an unannounced annual visit and was met by caregiver, Diana Rainey. LPA Spaeth observed the required COVID signs at the front door. The Caregiver opened the front door at 9:15 am and LPA observed caregiver was wearing a mask. Upon entering, the Caregiver took LPA's temperature, asked the COVID questions, and requested LPA to sign in at the sign in station. LPA observed the thermometer, and an adequate supply of PPE (masks, gloves, etc).. LPA confirmed there is a 90 day supply of PPE.

LPA observed the living room which contained comfortable furniture with a television. LPA was greeted by a resident who was wearing a mask. LPA confirmed there are five residents at the facility, three resident rooms, a staff room, and three bathrooms.

LPA observed the kitchen which contained a kitchen table, wash your hands sign, liquid soap, paper towels, and trash can. LPA observed an adequate supply of fresh vegetables, dairy products, and frozen meats in the refrigerator. LPA also observed an adequate supply of canned goods, the kitchen knives locked in a cabinet along with the resident medications.

LPA observed two resident bedrooms and saw rooms contained linens, twin beds (6 feet apart), lamp, lamp stand, and chest of drawers. The rooms were neat and clean. LPA observed the resident bathrooms and the staff bathroom. All contained wash your hands sign, paper towels, hand soap, and trash can. LPA observed there were no cleaning supplies under the bathroom sinks.

LPA observed the staff room, which is a locked room off from the kitchen. At 10:22 am, the caregiver unlocked the staff room, and LPA observed a locked room within the area which contained the washer and dryer. LPA observed the cleaning supplies and laundry soap within the locked room. LPA observed comfortable furniture outside and the side gate unlocked. There are no deficiencies to report. Exit interview conducted, appeal rights discussed, and a copy of the signed report given to the caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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