191204625-11-19-2024-31-AS-ASEA-DB6RP4-20241119121118

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191204625
Report Date: 11/19/2024
Date Signed: 11/19/2024 12:11:38 PM

Document Has Been Signed on 11/19/2024 12:11 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SPRING MEADOWS HOME		FACILITY NUMBER:	191204625
ADMINISTRATOR/ DIRECTOR:	VON BUCK, EARL A.		FACILITY TYPE:	735
ADDRESS:	43758 NORTH HARDWOOD		TELEPHONE:	(661) 942-2010
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	11/19/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:55 AM
MET WITH:	Dacia Von Buck		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/19/2024 at 9:50 AM, Licensing Program Analysts (LPAs), Angelica Segovia and Gina Saucedo conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by the Administrator Dacia Von Buck. LPAs stated the reason for their visit. LPA asked for census, staff, and resident files…. LPAs conducted a physical plant tour at approximately 11:00 AM and the following was noted: There is only one entrance being utilized at the facility. The facility is a single unit building with three (3) bedrooms and three (3) bathrooms currently occupying three (3) residents. The garage was converted to a staff room with its own bathroom. The facility is fire cleared for four (4) ambulatory residents. Required postings such as Emergency Disaster Plan, Administrator License, Personal Rights and Rights of Individuals with Developmental Disabilities were located at the main entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Living room observed to be neat, clean, and organized. Living room observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 68°F. Fire extinguisher located in the living room and dated 10/08/24. Fireplace observed to be covered inaccessible to residents. The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Knives and sharps observed to be locked alongside medication in the living room inaccessible to residents. Cleaning solutions are kept locked in the laundry room located within the staff room alongside the kitchen and inaccessible to residents. Stove observed to be working and in proper condition. Additional required postings were observed aside the kitchen such as: Yes poster. Dining table located within the kitchen. Dining room observed to be neat, clean, and properly furnished. (continued on LIC 809-C)

Troy Agard	TELEPHONE: (818) 596-4342
Angelica Segovia	TELEPHONE: (818) 669-6375
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SPRING MEADOWS HOME	FACILITY NUMBER: 191204625
	VISIT DATE: 11/19/2024

NARRATIVE

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The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water in this facility.

Smoke detectors and carbon monoxide observed to be working properly and were tested.

The laundry room can be accessed from the inside of the kitchen leading into the staff room and kept locked. The laundry room is equipped with an extra freezer and fully stocked with food. Laundry detergents, cleaning agents, and other toxins are stored in a locked cabinet in the laundry area inaccessible to residents.

The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Residents have sufficient personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at a range of 119.1°F. Towels and washcloths are not shared. Sufficient availability of clean lien and extra PPE stored in hallway cabinet.

Medications: LPAs observed medication in the living room stored in a locked cabinet and inaccessible to residents. Medication usage recorded and stored properly. LPAs along with Administrator conducted a review of the medication to ensure compliance. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual.

Resident records: LPAs conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPAs conducted a complete file review of staff records. Staff records appeared to be complete and updated.

An exit interview was conducted, Two (2) citations were issued for the conversion of the garage into a staff room without Department Approval, appeals rights and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Angelica Segovia	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/19/2024 12:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SPRING MEADOWS HOME	FACILITY NUMBER: 191204625
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Building and Grounds

(3) No room commonly used for other purposes shall be used as a bedroom for any person. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in one area which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/03/2024
	Plan of Correction
1 2 3 4	The admnistrator will advise you of building inspection permit and updates.

Section Cited

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in one area which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/03/2024
	Plan of Correction
1 2 3 4	The admnistrator will advise you of fire clearance and updates.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Troy Agard	TELEPHONE: (818) 596-4342
Angelica Segovia	TELEPHONE: (818) 669-6375
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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