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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191204625
Report Date: 12/05/2023
Date Signed: 12/05/2023 12:01:03 PM

Document Has Been Signed on 12/05/2023 12:01 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:
12/05/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Dacia Von BuckTIME COMPLETED:
12:00 PM
NARRATIVE
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LPA Smith made a subsequent visit to this facility at 10:20 am to complete annual inspection. Upon arrival LPA Smith observed construction being done. LPA knocked on door and rang doorbell and was greeted by a construction worker who revealed no one was home. The site contractor revealed the floors will be completed today and contacted the Administrator. LPA Smith spoke with the administrator who revealed will arrive at the facility shortly.

The administrator arrived at 10:50 am. Upon administrator arrival LPA finished tour.

There is one (1) Fire extinguisher in facility located in living room attached to mantel. Fire extinguisher observed to be charged.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit. All residents were at program at time of visit.

Deficiencies cited on 809-D



Exit Interview Conducted /Appeals/Copy of the Report Issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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Document Has Been Signed on 12/05/2023 12:01 PM - It Cannot Be Edited


Created By: Tihesha Smith On 12/05/2023 at 11:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SPRING MEADOWS HOME
FACILITY NUMBER: 191204625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as power tool and cement in front yard on bench which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Power tool and cement mixed were removed by Administrator at time of visit on 12/03/23. Item cleared.
Type A
Section Cited
CCR
87555


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed bananas and green vegetables black/brown and rotted which poses an immediate health, safety or personal rights risk to persons in care. 87555 (b) (28)
POC Due Date: 12/04/2023
Plan of Correction
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Rotted fruit/vegetables were discarded at time of visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


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Document Has Been Signed on 12/05/2023 12:01 PM - It Cannot Be Edited


Created By: Tihesha Smith On 12/05/2023 at 11:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SPRING MEADOWS HOME
FACILITY NUMBER: 191204625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above as mildew observed cracks in walls, repair needed behind sink need repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator will provided proof of repair/or request for repair date/information.
Type B
Section Cited
CCR
80088(e)(3)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above as shower only bathroom has mildew and need repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator/Licensee will provide proof of repairs and/or repair information.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/05/2023 12:01 PM - It Cannot Be Edited


Created By: Tihesha Smith On 12/05/2023 at 11:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SPRING MEADOWS HOME
FACILITY NUMBER: 191204625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview) , the licensee did not comply with the section cited above as administrator did not notify CCLD about construction/alterations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator will provide signed memorandum of understanding related to section cited.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
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