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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220139
Report Date: 11/03/2021
Date Signed: 11/03/2021 04:05:49 PM

Document Has Been Signed on 11/03/2021 04:05 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:AIDAS BOARD & CARE HOMEFACILITY NUMBER:
191220139
ADMINISTRATOR:MALLA, FLORIDAFACILITY TYPE:
735
ADDRESS:45546 GADSDEN AVENUETELEPHONE:
(661) 406-4256
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 3DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Florida MallaTIME COMPLETED:
03:00 PM
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LPA Melissa Spaeth conducted an unannounced visit and met the Administrator, Florida Malla at 1:30 pm. Upon arrival, LPA observed Administrator was wearing a mask. LPAs temperature was taken by the Administrator. LPA observed a supply of PPE near the front door available for guests if needed. Upon entering the front door, LPA observed the COVID signs posted on the front door. LPA observed the living room and dining room are one large room. The living room contained comfortable seating for residents. The dining room contained a dining room table and chairs.

LPA observed the three bedrooms which were neat and clean. Each bedroom contained a bed, linens, night stand and lamp. Also, the rooms contained chest of drawers and a closet for each resident. The Administrator confirmed there are two residents and each resident has their own room. One resident room is vacant. LPA observed the female resident relaxing in own room. LPA Spaeth observed the Administrator's private room which was locked.

When entering the hallway, LPA observed a locked cabinet which contained the resident medications. Each resident's medications were stored individually. LPA also observed resident hygiene items stored in the locked cabinet.

LPA observed the bathroom which contained wash your hands sign, hand soap, paper towels, and a trash can. LPA observed the medications were locked in a hallway cabinet. LPA Spaeth observed the slip resistant rug in the bathroom.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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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: AIDAS BOARD & CARE HOME
FACILITY NUMBER: 191220139
VISIT DATE: 11/03/2021
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LPA Spaeth observed the kitchen. The refrigerator contained fresh vegetables, fresh fruit and dairy products. The freezer section of the refrigerator contained frozen meats. The kitchen was also stocked with canned goods. LPA observed the locked kitchen cabinet which contained the cleaning supplies.

LPA Spaeth observed covered patio which contained comforrable furniture for all residents. There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed and a copy of the signed report was emailed to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
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