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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602319
Report Date: 06/01/2022
Date Signed: 06/01/2022 11:57:06 AM

Document Has Been Signed on 06/01/2022 11:57 AM - 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:A & W RESIDENTIAL CAREFACILITY NUMBER:
197602319
ADMINISTRATOR:TESS ASTUDILLOFACILITY TYPE:
735
ADDRESS:44503 21ST STREET WESTTELEPHONE:
(661) 945-2636
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 4DATE:
06/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tess AstudilloTIME COMPLETED:
12:10 PM
NARRATIVE
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At 10:30 a.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an annual inspection. Upon arrival, LPA was greeted by staff and staff granted access to home. LPA observed covid-19 signage posted outside the facility.LPA's temperature was not taken, was not asked to sign in the visitors log, and no covid-19 screening questions were asked. LPA later met with the Administrator Tess Astudillo, and the purpose of the visit was explained.

This is a five (5) bedroom two (2) bathroom Adult Residential Facility. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area. Carbon monoxide monitors were observed to be functional. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in a kitchen cabinet. Extra towels and linens were readily available. The backyard is clean, has a covered shaded area and there are no bodies of water.

Deficiencies issued per CA Code of Regulations, Title 22. Report was signed and delivered. An exit interview was conducted with the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2022
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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Document Has Been Signed on 06/01/2022 11:57 AM - It Cannot Be Edited


Created By: Melissa Ruiz On 06/01/2022 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A & W RESIDENTIAL CARE
FACILITY NUMBER: 197602319

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
8
87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee/staff did not comply with the cited section as staff is not screening visitors for symptoms of COVID 19 upon entry and staff was not wearing a mask, which poses and immediate Health and Safety and personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Licensee shall conduct in-house training with Administrator and all staff regarding covid-19 screening process and infection control mitigation plan. A written statement acknowledging the completion of training shall be signed by all staff shall be submitted to the LPA by e-mail by the POC due date of 6/3/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


LIC809 (FAS) - (06/04)
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