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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222665
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:05:03 PM

Document Has Been Signed on 10/06/2022 01:05 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:ANTELOPE VALLEY CARE HOMEFACILITY NUMBER:
191222665
ADMINISTRATOR:BIBIANA, LARAFACILITY TYPE:
735
ADDRESS:40712 171ST STREET EASTTELEPHONE:
(661) 264-3341
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 4DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Marie Bru, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Marie Bru for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:55 am and was greeted by a caregiver. Two (2) clients were observed in the living room watching TV. The Administrator arrived at 11:15 am. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was not screened by the caregiver and not asked to sign in. LPA did review the visitors log and visitors were screened and checked in. LPA reviewed with the Administrator that Licensing staff still needs to be screened.

A tour of the physical plant was conducted with Administrator at 11:25 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. One (1) bathroom and bedroom is designated for staff use only and the facility has awake staff at night. The facility is Fire Cleared for six (6) ambulatory.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 69°F. The smoke detectors were tested and observed to be operational at 11:40 am. There was no carbon monoxide detector found in the facility. At 12:04 pm a staff member brought and installed a new carbon monoxide detector. There are three (3) fire extinguishers, one (1) is located in the kitchen and two (2) are located in the hallway on each side of the house. The Fire extinguishers were observed to be full and last serviced on 05/04/22.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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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: ANTELOPE VALLEY CARE HOME
FACILITY NUMBER: 191222665
VISIT DATE: 10/06/2022
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Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client. All knives and sharp objects are locked and inaccessible to clients in care in the locked staff room.

Bathrooms
At 11:30 am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 115.5 degrees F.

Laundry
LPA observed chemicals/hazardous items in a locked closet in the laundry room, including client medications, PPE supplies, staff files, 1st aid kit, and an extra freezer.

Physical environment
LPA toured the outside area of the facility at 11:36 am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Food Inspection
LPA conducted a tour of the kitchen around 11:38 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests.

Garage
LPA observed the garage to be attached to the facility and currently being used for an extra storage and PPE supplies.

Administrative: LPA reviewed the LIC 500 and client roster. Annual fee is current.

An exit interview was conducted, citation issued, and a copy of this report and appeal rights was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2022 01:05 PM - It Cannot Be Edited


Created By: Shira Stamps On 10/06/2022 at 12:29 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: ANTELOPE VALLEY CARE HOME
FACILITY NUMBER: 191222665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections

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 in that there was no carbon monoxide detector present in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2022
Plan of Correction
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The Licensee will purchase a carbon monoxide detector, and provide the receipt to the LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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