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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191204625
Report Date: 12/03/2023
Date Signed: 12/03/2023 04:12:48 PM

Document Has Been Signed on 12/03/2023 04:12 PM - 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: 4CENSUS: 4DATE:
12/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Dacia Von BuckTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 10:24 am. Upon entry LPA Smith disclosed to staff the purpose of the visit. The administrator was not present at the facility and was contacted by staff.

LPA conducted a tour of the physical plant at approximately 10:50 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the living room and kitchen/dining room combination. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed and the following is noted:

The floors in the entire facility are being upgraded from carpet to hardwood floor laminate therefore items in pantry, living room and bedrooms have been relocated to either kitchen or backyard patio.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the four (4) residents currently residing there. Two (2) days of
perishable food observed. However, bananas and green vegetables located on table and counter had rotten. The freezer is stocked with meats and frozen vegetables. Food pantry located in hallway by front door.

Resident medications and sharps stored in locked metal cabinet. Medications and sharps observed to be locked and inaccessible to residents in care. Toxins are stored and locked in laundry room in wardrobe cabinet. The sharps are stored in locked metal cabinet in laundry room. There is one (1) fire extinguisher attached to wall in the kitchen and observed to be charged.

Laundry room is located in locked staff. The appliances observed to be functional.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2023
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SPRING MEADOWS HOME
FACILITY NUMBER: 191204625
VISIT DATE: 12/03/2023
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(cont. from 809)


The facility has four (4) bedrooms and two (2) bathrooms: for residents. There is also a converted staff room and bathroom for staff.

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet.

Each bathroom has the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 117.3- and 119.8 -degrees Fahrenheit.

Backyard has the following: Covered patio.

Locked Shed in backyard: Used for storage.

At approximately 1:00 -2:430 pm, LPA reviewed three (3) staff files. Staff files had the appropriate training's to include First aid and CPR and current administrators license. Four (4) out of four (4) resident files included physician’s reports and Individual Program plans.

Due to technical issues this annual inspection will be continued at a later time.

Exit Interview Conducted /Copy of the Report Issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2023
LIC809 (FAS) - (06/04)
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