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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602540
Report Date: 11/08/2021
Date Signed: 11/08/2021 11:59:12 AM

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: 41DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Mindy Mendoza-PerryTIME COMPLETED:
12:15 PM
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At 10:10 am, Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff who granted access to the facility and later met with Administrator Mindy Mendoza-Perry. This is a two-story residential care facility for the elderly. The facility has fire clearance for 61 non ambulatory, 7 bedridden residents. A physical tour was conducted at 10:35 am and observed the following:

Infection control: Proper signage was observed outside the facility and along the main entrance of the facility. Upon entrance, a designated covid-19 screening area was observed. Staff took LPA's temperature, asked infection control questions, and was asked to sign-in the visitor’s log. Hand sanitizer was available, and all trash cans were observed to have closed tight fitting lids. Sufficient PPE supplies were observed. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored in designated storage rooms throughout the facility and are kept locked. Smoke detectors/carbon monoxide were located throughout the facility. The latest fire alarm test was conducted 10/29/2021. Common Areas: These include the dining areas, TV areas, activity rooms, and library. All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 76.0 F. Bathrooms: The hot water temperature measured at 117.6 F. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. No deficiencies cited. An exit interview was conducted. A copy of this report was provided. Exit interview conducted.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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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