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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602319
Report Date: 06/18/2024
Date Signed: 06/18/2024 03:20:18 PM

Document Has Been Signed on 06/18/2024 03:20 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:A & W RESIDENTIAL CAREFACILITY NUMBER:
197602319
ADMINISTRATOR/
DIRECTOR:		TESS ASTUDILLOFACILITY TYPE:
735
ADDRESS:44503 21ST STREET WESTTELEPHONE:
(661) 945-2636
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 4DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Teresita Astudillo (Administrator)TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 06/18/2024 10:50 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced required annual inspection. LPA was greeted by staff #1(S1) Delfin Leonida and granted access. S1 informed LPA they would call the Administrator, Teresita Astudillo. Teresita informed LPA she is not in the area but will try to meet LPA. At this time administrator will be available by telephone. LPA explained the reason for the visit. Entrance Interview conducted.

The facility has four (4) bedrooms and two (2) bathrooms. One (1) bedroom is designated for live-in staff and has a private bathroom for staff use only. The facility has Fire Clearance for six (6) ambulatory clients.
A tour of the physical plant was conducted with S1 at approximately 11:00 a.m. and the following was observed:

Kitchen: LPA conducted a tour of the kitchen at approximately 11:00 a.m. and observed there to be sufficient supply of two-day perishables and seven-day non-perishable foods, properly stored. Food storage and preparation areas were clear of clutter. LPA observed inside the kitchen cabinets and drawers to have grease build up and food crumbs. LPA also observed cobwebs with a live spider on top of the fridge. LPA observed all knives, sharp object, locked in kitchen cabinet inaccessible to clients in care.

Living and dining areas: LPA observed the living area clear of clutter. The furniture sits the capacity of the facility. LPA observed a window by the living room missing a window boarded up with cardboard. At 11:10 a.m. LPA observed S1 test a smoke detector. Detectors do not appear interconnected. S1 was only able to test one (1) out of the four (4) observed in the facility. Smoke detector tested in the hallway was operational. Carbon monoxide detector was observed to be functioning properly. LPA observed one (1) fire extinguisher located by the kitchen, fully charged. (Continued to LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A & W RESIDENTIAL CARE
FACILITY NUMBER: 197602319
VISIT DATE: 06/18/2024
NARRATIVE
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Bedrooms: LPA inspected three (3) out of three (3) client bedrooms. Bedrooms can be shared. LPA observed each client room to be furnished with one bed, two night stands and one closet. LPA observed four (4) beds without a protective cover, fitted sheet and flat sheet. LPA observed extra linens in a hallway closet. LPA observed bedroom door to room labeled #2 not open all the way. An item was blocking the door only allowing LPA to open the door slightly. LPA was able to observe the room had furniture, the window was boarded up and the client has personal items hanging from the ceiling such us clothes and a bicycle. Bedroom labeled #3 has a sliding glass door that was missing a handle to open and close the sliding door.

Bathrooms: The facility has one (1) bathroom for client use. LPA took the hot water temperature from the bathroom and temperature was 108 degrees F. LPA observed the bathroom to be properly supplied with hand soap, toilet paper and paper towels. LPA observed the caulking from around the bathtub to be black.



Laundry: Laundry area is located outside and is accessible to clients and staff.

Surrounding Grounds: Entry and exits were free of obstructions. LPA observed a table and chairs for client use.

Client/Staff Records: At approximately 1:22 p.m. four (4) out four (4) client records and (2) staff records were reviewed to insure compliance with licensing forms. Records are kept locked in staff room.

Medications: Centrally stored medications are maintained locked in a kitchen cabinet. Medications were observed locked. Refills are either done automatically or ordered by the physician. Medication Records were reviewed for proper documentation.

Pursuant to Title 22 Division of the CA Code of Regulations, there were deficiencies observed during todays visit (refer to 809-D). Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/18/2024 03:20 PM - It Cannot Be Edited


Created By: Evelin Rios On 06/18/2024 at 02:09 PM
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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, and interviews, the licensee did not comply with the section cited above in two (2) missing windows boarded up with cardboard, one floor tile missing, grease and crumbs in kitchen cabinets and drawers, one (1) sliding door in client's bedroom missing handle and bathroom has caulking that has gone black which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Administrator agreed to involve the landlord in plan to have items mentioned above repaired. Administrator will submit pictures to LPA when repairs are made by POC due 07/18/2024.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in live spiders observed in the kitchen and through out the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Administrator agreed to have staff clean the facility of cobwebs and spiders and send picture of the top of refrigerator to LPA by POC due date 07/18/2024.
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:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/18/2024 03:20 PM - It Cannot Be Edited


Created By: Evelin Rios On 06/18/2024 at 02:09 PM
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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with the administrator, the licensee did not comply with the section cited above in two (2) out of two (2) staff having expired first aid certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Administrator agreed to complete first aid certification and submit completion certificates to LPA by POC due date 07/18/2024.
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:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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