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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602356
Report Date: 09/20/2021
Date Signed: 09/20/2021 12:45:42 PM

Document Has Been Signed on 09/20/2021 12:45 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:ANA RESIDENTIAL CAREFACILITY NUMBER:
197602356
ADMINISTRATOR:SMITH, WANDAFACILITY TYPE:
740
ADDRESS:1046 EAST LANCASTER BOULVARDTELEPHONE:
(661) 949-0151
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 4DATE:
09/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Wanda SmithTIME COMPLETED:
12:15 PM
NARRATIVE
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LPA Spaeth arrived at the facility at 11:40. LPA was greeted by Administrator, Wanda Smith. LPA Spaeth stated the purpose of the visit is regarding an incident that occurred at the facility. Licensing Program Analysts (LPA) Melissa Spaeth conducted an unannounced Case- Management - Incident visit. The purpose of this visit is to follow up on a special report submitted to the department on July 7, 2021.

The licensee reported that on 07/07/2021 two residents (R1 and R2) were involved in two inappropriate encounters within the facility. The two encounters both occurred on the same day and was reported to Administrator by caregiver. During this visit LPA reviewed R1's file at 11:45 am.

Based upon LPA's review of the R1's file and under Title 22 General Regulations, the following citations were issued and recorded on LIC 809D.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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 09/20/2021 12:45 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/20/2021 at 10:54 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: ANA RESIDENTIAL CARE
FACILITY NUMBER: 197602356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited
CCR
87705(5)

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87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, & reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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Administrator will have resident physician's report completed by the resident's doctor.
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This was not met based upon: LPA reviewed R1's records and observed the last medical assessment completed for R1 took place on April 25, 2019.
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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:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021


LIC809 (FAS) - (06/04)
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