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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191240840
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:59:29 PM

Document Has Been Signed on 07/21/2022 03:59 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:GOLTZ ADULT HOMEFACILITY NUMBER:
191240840
ADMINISTRATOR:CLIFTON VON BUCKFACILITY TYPE:
735
ADDRESS:1009 WEST AVE H-4TELEPHONE:
(661) 433-9632
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 5DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Flosie TamaliuanTIME COMPLETED:
02:00 PM
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LPA Spaeth was greeted by staff member (S1) and also another staff member (S2); both caregivers were wearing a mask. LPA observed the COVID signs on the door and observed the sign in station. LPA's temperature was taken and recorded on the sign in sheet. LPA answered COVID questions. The sign in station contained hand sanitizer, thermometer, & masks. S1 stated there are five residents living in the facility.

LPA observed the dining room and observed five residents were eating lunch. Upon entering the living room, LPA observed a resident in the living room listening to the radio. The living room contained comfortable furniture and a television. LPA toured the three bedrooms which contained a bed for each resident, chest of drawers, linens, lamp, night stand, and a chair. Residents share a room and observed the twin beds were six feet apart.

There are two bathrooms in the facility which contained wash your hands sign, slip resistant mat, hand soap, electric hand dryers, and trash can.

Upon entering the kitchen, LPA observed wash your hands sign, hand soap, paper towels, and trash can. The cabinet underneath the sink was locked and contained cleaning supplies. The knives and medications were locked in a kitchen cabinet. The refrigerator contained fresh vegetables, dairy products, and fresh fruit. The freezer section of the refrigerator contained frozen meats. The staff room is located on the west side of the facility and can be accessed through the kitchen. The staff room was locked. LPA observed the fire extinguisher was located in the kitchen. LPA exited the facility through the sliding glass doors that lead to the backyard. LPA observed the washer and dryer are located on the side of the house in a shed. The side gate was not locked.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed & a copy of the report was given to S1.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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