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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602356
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:25:36 PM

Document Has Been Signed on 07/23/2024 03:25 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANA RESIDENTIAL CAREFACILITY NUMBER:
197602356
ADMINISTRATOR/
DIRECTOR:		SMITH, WANDAFACILITY TYPE:
740
ADDRESS:1046 EAST LANCASTER BOULVARDTELEPHONE:
(661) 949-0151
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 3DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Wanda SmithTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Lorena Casillas arrived at 09:45 am for an unannounced one (1) year Required visit for this facility. LPA met with the Administrator Wanda Smith. Entrance interview conducted.

LPA and the Administrator conducted a tour of the facility at 10:00 am. The following was observed:

Infection control: The facility has a Mitigation Plan approved on 03/30/2021. Proper signs were observed inside along the hallway and in the restrooms.

Common Areas: LPA toured all common areas of the facility. LPA observed common areas to be clean and furniture to be in good repair. The facility maintains a comfortable temperature at 80 degrees F. LPA observed fire extinguisher to be full and last serviced on 9/1/23. At 10:20 am, LPA tested and verified all the carbon monoxide and smoke detectors were operational.

Kitchen: At 10:15 am LPA toured the kitchen area and observed enough supplies of non-perishables for seven (7) days and perishables for two (2) days at the facility. Snacks and beverages are available for residents in the facility when they want. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

Resident rooms: LPA observed rooms to have appropriate bedding sheets, pillowcase, mattresses, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. LPA tested the door alarm system, and it was observed to be operational.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANA RESIDENTIAL CARE
FACILITY NUMBER: 197602356
VISIT DATE: 07/23/2024
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Bathrooms: At 10:20 am LPA observed the bathrooms to have non-skid mats, grab bars, and wash your hands signs posted. Residents have enough supplies for personal hygiene which is provided by the Licensee. Hot water measured at 116.9 degrees F.

Outside areas: LPA toured the outside area of the facility at 10:25 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA observed no bodies of water on the premises.



Laundry/Garage: LPA observed the laundry room to be in the hallway. Chemicals and laundry detergent are stored in the locked garage. The garage is currently being used for storage and there is an extra refrigerator and freezer. LPA observed the first aid kits located in a locked hallway cabinet.

Resident Files: LPA conducted a file review of resident records at 01:00 pm.

Staff Files: LPA conducted a file review of staff records at 02:00 pm.

Medications: LPA and Administrator reviewed medication and medication records for proper documentation.

Interviews: At 03:15 pm LPA interviewed residents and staff.

Administrative: LPA collected Certificate of Liability Insurance, resident roster, Administrator Certificate and LIC.500. Annual fee is current.

No citations issued. Exit interview conducted. Copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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