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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191291008
Report Date: 09/08/2022
Date Signed: 09/08/2022 04:53:49 PM

Document Has Been Signed on 09/08/2022 04:53 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:SPRING MEADOWS HOME IIFACILITY NUMBER:
191291008
ADMINISTRATOR:VON BUCK, DACIA L.FACILITY TYPE:
735
ADDRESS:44819 N. INOLATELEPHONE:
(661) 945-4990
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: 4DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rick HillTIME COMPLETED:
03:17 PM
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LPA Spaeth conducted an unannounced visit and was greeted by caregiver Rick Hill and a resident. LPA's temperature was recorded and COVID questions were completed by LPA Spaeth. LPA observed the sign in station at the front door. The sign in sheet, hand sanitizer, masks, and thermometer were available at the front door.

LPA and caregiver began the tour at 3:05 pm and LPA observed the facility was neat a clean. Upon entering the kitchen LPA observed the refrigerator was stocked with fresh vegetables and fruits and the freezer section contained frozen meats. LPA observed the cleaning products were locked in the kitchen cabinet. An additional freezer is located in the office and contained additional frozen meats and vegetables. LPA observed the knives and medications were locked in a cabinet in the office.

LPA observed the three bathrooms contained hand soap, paper towels, wash your hands sign, and a trash can. LPA also observed the staff room was locked. Upon entering, LPA observed a six month supply of PPE stored in the staff room closet. LPA observed all resident rooms contained bed, linens, night stand, lamp, chest of drawers and a closet.

Upon exiting to the backyard, LPA observed the washer and dryer are located in a locked building and the shed was also locked. The gate leading from the backyard to the front door was not locked.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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