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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191240840
Report Date: 07/20/2024
Date Signed: 07/20/2024 03:39:21 PM

Document Has Been Signed on 07/20/2024 03:39 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOLTZ ADULT HOMEFACILITY NUMBER:
191240840
ADMINISTRATOR/
DIRECTOR:		CLIFTON VON BUCKFACILITY TYPE:
735
ADDRESS:1009 WEST AVE H-4TELEPHONE:
(661) 433-9632
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 1DATE:
07/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:39 PM
MET WITH:Reuel Tumaliuan - StaffTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA initially met with staff Reuel Tumaliuan who called the administrator Clifton Von Buck. Purpose of the visit is stated. This is a North Los Angeles Regional Center vendored facility Level III. Mr. Von Buck designated Mr. Tumaliuan to sign the report.

LPA conducted physical plant tour inside and out at 12:48 PM. During the tour, LPA observed that the facility has four (4) bedrooms and three (3) bathrooms. One (1) bedroom and one (1) bathroom is designated for staff use. The swimming pool was appropriately fenced, no water and had not been used and observed to be locked during visit.

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

Signs of Covid 19 prevention protocol signs were inside the facility. Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

Bedrooms were toured and observed to be clean and appropriately furnished,

Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 115.1°F to 116.8°F.

(continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLTZ ADULT HOME
FACILITY NUMBER: 191240840
VISIT DATE: 07/20/2024
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions and laundry detergents were observed to be locked in the cabinet below the kitchen sink.
Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguisher was observed to be located by the kitchen. Extinguisher was observed to be operable and last checked on 04/18/24. Smoke alarms were tested and observed to be operational. There was a carbon monoxide installed in the facility.

Medication was observed to be locked, inaccessible and stored in the kitchen cabinet. Medication records and procedures reviewed with staff. There was a complete first aid kit located in the wall near the main entrance. Knives and sharps are locked and secured in the cabinet below the kitchen sink.

Garage is detached to the house and observed to be locked and inaccessible to clients. Garage is also used as supplies, non-perishable, frozen food, and emergency supplies storage.

Client records were also reviewed. Client record appeared to be complete and current.

Staff records were also reviewed. Staff present had criminal record clearances and associated to this facility.
Current training and first aid/CPR observed for staff on duty.

Disaster drills was last conducted on 07/01/24. Required posting observed in facility (complaint hot line poster).

Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024
LIC809 (FAS) - (06/04)
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