<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222665
Report Date: 09/18/2024
Date Signed: 09/18/2024 01:29:55 PM

Document Has Been Signed on 09/18/2024 01:29 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANTELOPE VALLEY CARE HOMEFACILITY NUMBER:
191222665
ADMINISTRATOR/
DIRECTOR:		BIBIANA, LARAFACILITY TYPE:
735
ADDRESS:40712 171ST STREET EASTTELEPHONE:
(661) 264-3341
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 4DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Marie Lara BruTIME VISIT/
INSPECTION COMPLETED:
01:50 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 Analyst (LPA) Lorena Casillas met with Administrator Marie Lara Bru for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:00 am and there was no one at the door. LPA Casillas called Administrator and Administrator said that they would be at facility as soon as possible. Administrator arrived shortly after, and LPA informed the Administrator of the purpose of the visit. All four (4) clients were at day program.

Infection control: LPA reviewed infection control 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 11:00 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. There are two (2) clients on one bedroom and one (1) client each in the remaining rooms.

Kitchen: LPA conducted a tour of the kitchen around 11:10 pm and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests.

Common Areas: LPA 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 11:30 am. 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 04/18/24.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 09/18/2024
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
26
27
28
29
30
31
32
Bedrooms: LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client. All knives and sharp objects are locked and inaccessible to clients in care in the locked staff room that was opened for LPA.

Bathrooms: LPA observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested at 11:20 am and measured within regulation 116.0 degrees F.

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

Physical environment: LPA toured the outside area of the facility at 11:25 am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

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

Client/Staff Files: LPA conducted a file review of client and staff records at 11:30 am.

Client/Staff Interviews: All clients were a day program. LPA conducted staff interview at 1:15 pm.

Medications: At 01:25 pm LPA and Administrator reviewed medication and medication records for proper documentation.

Administrative: LPA collected LIC 500, Bond and Client roster. The annual fee is current.

No citations issued. Exit interview conducted. Copy of this report provided to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2