197602540-11-9-2022-31-AS-ERIS-CKZRFR-20221109115935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602540
Report Date: 11/09/2022
Date Signed: 11/09/2022 11:59:44 AM

Document Has Been Signed on 11/09/2022 11:59 AM - 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:	PRESTIGE ASSISTED LIVING AT LANCASTER		FACILITY NUMBER:	197602540
ADMINISTRATOR:	MINDY MENDOZA-PERRY		FACILITY TYPE:	740
ADDRESS:	43454 30TH STREET WEST		TELEPHONE:	(661) 949-2177
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	68	CENSUS: 62	DATE:	11/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Michael Gonzalez		TIME COMPLETED:	12:15 PM

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At 9:45 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced annual inspection at the facility mentioned above. LPA signed in and was screened by automated system before approaching reception desk. LPA was greeted by staff and later met with House Service Director (HSD) Michael Gonzalez. This is a two-story residential care facility for the elderly. A physical tour was conducted at 10:00 a.m., LPA and HSD 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. A machine took LPA's temperature, LPA answered infection control questions on a computer screen, and was prompted to sign-in the digital visitor’s log. Hand sanitizer was available, and all trash cans were observed to have closed tight fitting lids. Sufficient PPE supplies were observed.

KItchen/Food Inspection: LPA observed 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.

Medication: Medications are centrally stored in designated room and are kept locked.

Smoke detectors/carbon monoxide/ Fire Extinguisher: Smoke detectors/carbon monoxide were located throughout the facility. The last fire alarm test was conducted 10/23/2022. Fire extinguishers appeared to be fully charged and service tag displayed last serviced date 09/06/2022.

Call button / Delayed Egress Alarm: At approximately 10:00 a.m. three (3) different call buttons in residents' rooms were tested and found to be functioning properly. At approximately 10:24 a.m. delayed egress alarms were tested and functioning properly.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESTIGE ASSISTED LIVING AT LANCASTER	FACILITY NUMBER: 197602540
	VISIT DATE: 11/09/2022

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Common Areas: These include the dining areas, TV areas, activity rooms, and sitting areas. All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 75 F.

Bathrooms: The hot water temperature measured at 119.3 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.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC809 (FAS) - (06/04)

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