191222665-10-20-2023-31-AS-LCAS-CWSS5A-20231020133401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222665
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:34:07 PM

Document Has Been Signed on 10/20/2023 01:34 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:	ANTELOPE VALLEY CARE HOME		FACILITY NUMBER:	191222665
ADMINISTRATOR:	BIBIANA, LARA		FACILITY TYPE:	735
ADDRESS:	40712 171ST STREET EAST		TELEPHONE:	(661) 264-3341
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 6		CENSUS:	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Bibiana Marie Bru		TIME COMPLETED:	02:00 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	Licensing Program Analysts (LPAs) Lorena Casillas and Melissa Spaeth met with Administrator Marie Bru for an unannounced one (1) year Required visit for this facility. LPAs arrived at 10:15 am and there was no one at the door. LPA Casillas called Administrator and she said that she would be at facility in approximately 45 minutes. Administrator showed up at 11:30 am. LPAs informed the Administrator of the purpose of the visit. Infection control: LPAs reviewed facility mitigation plan (approved on 10/17/2022) to make sure licensee was following current infection control recommendations. A tour of the physical plant was conducted with Administrator at 12:12 pm. 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. The facility is Fire Cleared for six (6) ambulatory. Living and dining LPAs observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors were tested and observed to be operational at 12:20 pm. 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 fully charged and last serviced on 05/02/23. CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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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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: ANTELOPE VALLEY CARE HOME	FACILITY NUMBER: 191222665
	VISIT DATE: 10/20/2023

NARRATIVE

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Resident Rooms
LPAs 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
LPAs observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested at 11:20 am and measured within regulation between 105 degrees F and 120.0 degrees F.

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

Physical environment
LPAs toured the outside area of the facility at 12 20 pm. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Food Inspection
LPAs conducted a tour of the kitchen around 12:38 pm 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 are clean and inaccessible to pests.

Garage
LPAs observed the garage to be attached to the facility and currently being used for extra storage.

Resident Files:
LPAs conducted a file review of resident records to ensure compliance of licensing forms at 12:30 pm.

CONTINUED....

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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: ANTELOPE VALLEY CARE HOME	FACILITY NUMBER: 191222665
	VISIT DATE: 10/20/2023

NARRATIVE

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Resident Files:
LPAs conducted a file review of resident records to ensure compliance of licensing forms at 12:30 pm.

Staff Files:
LPAs conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms at 01:00 pm.

Medications:
At 01:25 pm LPAs and staff reviewed medication and medication records for proper documentation.

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

An exit interview was conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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