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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602540
Report Date: 11/16/2020
Date Signed: 11/17/2020 04:39:40 PM

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:PRESTIGE ASSISTED LIVING AT LANCASTERFACILITY NUMBER:
197602540
ADMINISTRATOR:MINDY MENDOZA-PERRYFACILITY TYPE:
740
ADDRESS:43454 30TH STREET WESTTELEPHONE:
(661) 949-2177
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:68CENSUS: 50DATE:
11/16/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Mindy Mendoza-Perry, AdministratorTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Rosaura Valenzuela and Naira Margaryan conducted a case management visit for an exemption denial. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, today's visit was conducted by face time video conference with the facility administrator Mindy Mendoza-Perry.

The LPAs conducted a face time video conference with Ms. Mendoza-Perry at 2:17pm on 11/16/2020, in which a physical plant tour was conducted and the administrator was interviewed. Administrator indicated that the facility does not request exemptions for employees and furthermore stated that the employee whose exemption was denied by the Department, was never hired or worked at the facility.

LPA Valenzuela requested on 11/16/2020 at 2:37pm a copy of the LIC 500. LPA reviewed the LIC 500 and was able to confirm that the employee in question, is not employed by the facility.

LPAs were able to confirm that the employee whose exemption was denied by the department is and was not employed by the facility.

Exit interview conducted. Signature obtained on hard copy of the report.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
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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