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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191291008
Report Date: 12/10/2023
Date Signed: 12/10/2023 12:30:46 PM

Document Has Been Signed on 12/10/2023 12:30 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:
12/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Dina AlvarezTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPA) Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 8:20 am. LPA disclosed to staff the purpose of the visit and the administrator was contacted. The administrator was not available to come to facility and authorized staff to sign.

LPA conducted a tour of the physical plant at approximately 9:15 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the kitchen, dining room area and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the four (4) residents currently residing there.

The resident medications are locked in a cabinet on top of desk in office area. The medications were observed to be inaccessible to residents. There is one (1) fire extinguisher located in the kitchen attached to wall. Fire extinguisher observed to be charged.

The facility has three (3) bedrooms and three (3) bathrooms: There is also a converted room that is currently used as a couple resident room.

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet.

(Cont. to 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 191291008
VISIT DATE: 12/10/2023
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(cont from 809)

Each bathroom has the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 106.9, 110.1- and 114.6 -degrees Fahrenheit.

Backyard has the following: Pergola patio with sufficient seating for residents.

Laundry room in backyard detachment area. Appliances observed to be in good repair. Room next to laundry area appears to be occupied per staff.

At approximately 10:05 am, LPA Smith reviewed infection control plan and four (4) resident files. Four (4) out of four (4) resident files included physician’s reports and Individual Program plans. At 11:05 am, LPA interviewed 2 of 4 residents.

Due to time constraints this required annual will be completed at a later time.

Exit interview conducted/Copy of report given
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2023
LIC809 (FAS) - (06/04)
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