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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191240840
Report Date: 10/28/2022
Date Signed: 10/28/2022 11:58:54 AM

Document Has Been Signed on 10/28/2022 11:58 AM - 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:
10/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:15 AM
MET WITH:Flosie TumaliuanTIME COMPLETED:
08:15 AM
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LPA Spaeth conducted an unannounced visit and was greeted by caregiver. LPA stated the purpose of the visit was regarding an incident that occurred at the facility. Caregiver was wearing a mask when greeted LPA and confirmed there are five residents. LPA observed two residents waiting for transportation to an adult day program. Both residents confirmed had breakfast and LPA observed lunch bag that was prepared by caregiver.

LPA and Caregiver began tour at 7:45 am until 8:00 am. LPA observed the living room which was neat and clean. Both parties entered the kitchen and LPA observed the knives were locked in a secure area in the staff's room. The medications were locked in the kitchen cabinet. The facility is supplied with a three day supply of fresh meats, vegetables and fruits. The pantry contained a seven-day supply of canned goods. Paper towels, hand soap, wash your hands sign, and trash can were located near the kitchen sink.

LPA also observed the two bathrooms contained wash your hands sign, hand soap, motorized hand dryer, and trash can. There are no deficiencies to report this time. Exit interview conducted and a copy of the report was given to the Caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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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