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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191204625
Report Date: 11/02/2022
Date Signed: 11/03/2022 08:37:17 AM

Document Has Been Signed on 11/03/2022 08:37 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:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Susie LaraTIME COMPLETED:
03:30 PM
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LPA Spaeth conducted an unannounced visit and was greeted by Caregiver. Upon arrival, LPA observed the COVID signs at the entrance. LPA's temperature was recorded and LPA was asked the COVID questions. The entrance area also contained additional masks. LPA observed caregiver was wearing a mask. LPA stated the purpose of the visit was to conduct the annual inspection. The caregiver confirmed there are five residents living in the facility. At 2:35 pm, LPA observed two residents arriving to the facility after attending the adult day program. LPA and Caregiver began the tour at 2:38 pm.

LPA observed comfortable seating along with a television in the living room. The medications were locked in a cabinet in the living room. Upon entering the kitchen, LPA observed the caregiver was preparing chicken and vegetable soup for dinner. LPA observed the knives were locked in a kitchen cabinet. LPA observed a three day supply of fresh fruits and vegetables. LPA observed a seven day supply of canned goods. LPA observed there were no harmful chemicals underneath the kitchen sink. LPA observed a kitchen table was in the kitchen. LPA observed the laundry room was also locked and contained the laundry detergent and cleaning supplies. LPA also observed a 90 day supply of PPE stored in the living room.

There are three resident rooms which all contained a bed, linens, night stand, lamp and chest of drawers. There are two bathrooms which contained wash your hands sign, hand soap, paper towels, and a trash can. The backyard contained comfortable seating and the side gate leading to the front yard was not locked.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a co9y of the report was given to the caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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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