<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191291008
Report Date: 10/06/2024
Date Signed: 10/06/2024 12:28:00 PM

Document Has Been Signed on 10/06/2024 12:28 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:SPRING MEADOWS HOME IIFACILITY NUMBER:
191291008
ADMINISTRATOR/
DIRECTOR:		VON BUCK, DACIA L.FACILITY TYPE:
735
ADDRESS:44819 N. INOLATELEPHONE:
(661) 945-4990
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: 4DATE:
10/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Dacia Von buck - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA initially met with staff Dina Alvarez who called the administrator Dacia Von Buck. Purpose of the visit is stated. Ms. Von Buck arrived 20 minutes later. This is a North Los Angeles Regional Center vendored facility Level II.

LPA conducted physical plant tour inside and out at 9:42 AM. During the tour, LPA observed that the facility has four (4) bedrooms and three (3) bathrooms. One (1) bedrooms is designated for staff use. The swimming pool is appropriately fenced and was locked during visit. The swimming pool has no water and not been operational as it has grown grasses and weeds in it.

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 to wear a mask and other Covid 19 prevention protocol signs were posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage

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 113.1°F to 113.2°F. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SPRING MEADOWS HOME II
FACILITY NUMBER: 191291008
VISIT DATE: 10/06/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(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 other toxins were observed to be locked in the cabinet below the 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 bought on 10/06/24. Fire alarms are hardwired and observed to be operational. There is a carbon monoxide detectors installed in the facility.
Medication were observed to be locked, inaccessible and stored in the cabinet in the office area located in the bedroom hallway. There were two (2) complete first aid kits located in office area. Knives and sharps are locked and secured in the medication cabinet
There is no Garage at the facility only driveway leading to the backyard. The backyard has an additional dwelling unit (ADU) being rented. The renter was finger print cleared. There is also a tool shed being used as storage. The shed was observed to be locked during visit. Laundry room is located in the ADU. Laundry detergents, cleaning agents and other toxins are kept in a locked cabinet in the staff room.
Client records. All of four (4) client records were reviewed. Clients record appeared to be complete and current. Staff records were also reviewed. All staff present records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 09/30/24. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no health and safety hazard observed during the day of inspection. 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: 10/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2