191240840-11-28-2023-31-AS-CALH-CXZULR-20231128144109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191240840
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:41:51 PM

Document Has Been Signed on 11/28/2023 02:41 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:	GOLTZ ADULT HOME		FACILITY NUMBER:	191240840
ADMINISTRATOR:	CLIFTON VON BUCK		FACILITY TYPE:	735
ADDRESS:	1009 WEST AVE H-4		TELEPHONE:	(661) 433-9632
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY: 6		CENSUS: 2	DATE:	11/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Flosie Tumaliuan		TIME COMPLETED:	02:45 PM

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On 11/28/23 at 10:30AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – 1 Year Inspection at GOLTZ ADULT HOME and met with staff (S2) Flosie Tumaliuan LPA explained the purpose of the visit and were accompanied by S2 inside and outside the facility during this inspection.

At 11:00 AM LPA conducted a plant tour. Facility temp measured at 71 degrees. The facility consists of 3 client bedrooms, 1 staff bedroom, 1 bathroom, a living room, dining room, laundry room and kitchen.

This facility is licensed to serve 6 adults ages 18 – 59 years. A total of 2 clients are currently residing in this facility, 2 out of 2 clients are ambulatory. A total of two staff and one client were present during this inspection. Bedroom #3 is designated for non-ambulatory residents.

Outside grounds were toured. The swimming pool was appropriately fenced, no water and it's not being used. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

3 out of 3 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Alemoh tested hot water temperature in the middle hallway client restroom, and it measured between 117- and 118.1 degrees Fahrenheit. This facility provides clients with residents with hygiene products such as feminine napkins, non medicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Located in the rear pantry next to the refrigerator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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: GOLTZ ADULT HOME	FACILITY NUMBER: 191240840
	VISIT DATE: 11/28/2023

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LPA observed that Medications were safe, locked in a cabinet and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. All Medication and knives are stored in a cabinet adjacent to the kitchen. Documents are posted as mandated. The last Disaster drill was conducted on 10/20/23. The first aid kit is fully stocked with manual located next to the front door. Smoke and carbon monoxide detectors are battery operated and in compliance and operational. One Fire Extinguishers were observed throughout the facility purchase date is March 23rd, 2023.

At 1200 PM LPA reviewed Four (4) staff records were reviewed, 4 out of 4 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Two (2) client records were reviewed and, 2 out of 2 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. LPA Alemoh reviewed P&I money, 2 out of 2 residents P&I were intact and were not commingled with facility funds or petty cash. All client/resident and staff files are locked in small cabinets in the middle hallway inaccessible to residents.

No deficiencies cited.

An exit interview was conducted. A copy of this report and appeal rights were discussed and left with Caregiver Flosie Tumaliuan.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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