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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220139
Report Date: 10/13/2022
Date Signed: 10/14/2022 12:29:32 PM

Document Has Been Signed on 10/14/2022 12:29 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: 2DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Florida MallaTIME COMPLETED:
01:30 PM
NARRATIVE
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LPA Melissa Spaeth conducted an unannounced visit and met the Administrator, Florida Malla at 12:30 pm. Upon arrival, LPA observed Administrator was wearing a mask. Administrator confirmed there two residents. LPA observed one resident in the living room. Administrator confirmed the other resident was out of the facility. 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 viewed the resident rooms which contained a bed, linens, night stand and lamp. Also, the rooms contained chest of drawers and a closet for each resident. One resident room is vacant. 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 LPA Spaeth observed the wash your hands sign, paper towels, and hand soap. Both parties entered the kitchen LPA observed a seven day supply of canned goods and a two day supply of fresh food in the refrigerator. At 12:20 pm, LPA observed the knives were on the counter; LPA requested Administrator to lock knives and Administrator locked the knives in the kitchen cabinet underneath the sink. LPA also observed the cleaning supplies were locked in the kitchen cabinet underneath the sink. Based upon LPA observations, a deficiency was observed. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D). LPA Spaeth Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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Document Has Been Signed on 10/14/2022 12:29 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 10/13/2022 at 01:07 PM
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: AIDAS BOARD & CARE HOME
FACILITY NUMBER: 191220139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2022
Section Cited

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80087 Building & Grounds (e) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This was evidenced by:
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During LPA's observations, LPA observed the knives were not locked in a kitchen cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
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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:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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