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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600845
Report Date: 05/09/2022
Date Signed: 05/09/2022 06:39:47 PM

Document Has Been Signed on 05/09/2022 06:39 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:APPLE STREET, LARC HOMEFACILITY NUMBER:
197600845
ADMINISTRATOR:ROSE MARIE SALGADOFACILITY TYPE:
735
ADDRESS:24624 APPLE STREETTELEPHONE:
(661) 259-2009
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 6CENSUS: DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Bertha ChavarinTIME COMPLETED:
03:18 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Bertha Chavarin for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 12:30pm and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a storage closet located in the facility's office and garage. The facility has a total of four (04) bedrooms, of which one (01) is for staff, and three (03) bathrooms, of which one (01) is for staff. The facility is fire cleared for six (06) non-ambulatory clients. The facility is currently occupying four (04) non-ambulatory clients. The facility does not have a swimming pool/body of water. The garage is being used for storage. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet. Food Service/Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.
Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living and dining room furniture were also checked. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located throughout the facility, observed to be full and last inspected on 09/22/2021.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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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: APPLE STREET, LARC HOME
FACILITY NUMBER: 197600845
VISIT DATE: 05/09/2022
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Staff room was observed to be locked and located adjacent to the facility office. No medications are observed in the staff room. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 116.9°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinets. LPA observed medication and a complete first aid kit to be locked and inaccessible to residents, located in the office.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC809 (FAS) - (06/04)
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