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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603228
Report Date: 02/10/2022
Date Signed: 02/18/2022 01:59:30 PM

Document Has Been Signed on 02/18/2022 01:59 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:ANTELOPE VALLEY FOUNDATION, INC.FACILITY NUMBER:
197603228
ADMINISTRATOR:DAVENPORT, GAMZEFACILITY TYPE:
735
ADDRESS:36448 RODEO STREETTELEPHONE:
(661) 533-0974
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 3DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gamez Davenport, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Gamze Davenport for an unannounced one (1) year Required visit for this facility. LPA arrived at 10:00 am and was greeted by caregiver Robert Davenport. All residents were observed to be in their room sleeping, and/or resting. At 10:15am, the Administrator stated she was on her way. LPA informed the caregiver of the purpose of the visit and began the tour. The Administrator arrived at 11:55am.

Infection control: LPA Stamps reviewed facility mitigation plan (approved on 03/13/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver. LPA was asked to sign-in and sanitize was available.

A tour of the physical plant was conducted with the Caregiver at 10:52 am. The facility has six (6) bedrooms and two (2) bathrooms currently occupying three (3) residents. Two (2) bedrooms are designated for staff use only. The facility is Fire Cleared for six (6) ambulatory.

Food Inspection
LPA conducted a tour of the kitchen around 11:00 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. LPA observed chemicals/hazardous cleaning supply on the kitchen counter.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY FOUNDATION, INC.
FACILITY NUMBER: 197603228
VISIT DATE: 02/10/2022
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Bathrooms
At 11:05 am LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted. The hot water was tested at 11:07 am and measured within regulation at 107.6 degrees F. LPA observed cleaning solutions in the first floor bathroom accessible to clients in care.

Laundry
At 11:01 am, LPA observed the laundry room. LPA observed the chemicals/hazardous items, knives, and sharp objects locked in the hallway closet inaccessible to clients in care.

Physical environment
LPA toured the outside area of the facility at 11:12 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises. LPA observed an old couch outside, that is to be picked up for the dump in March 2022.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 78°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:28 am. There are four (4) fire extinguisher located in the living room. The fire extinguishers were observed to be full and last serviced on 01/22/22. LPA observed the medication cabinet locked and inaccessible to clients in care.

Garage
At 11:10 am, LPA observed the garage to be attached to the facility and currently being used for an extra storage and two extra refrigerators.

Administrative: LPA collected the resident roster and the Staff Schedule. Annual fee is current.


An exit interview was conducted, citation issued, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2022 01:59 PM - It Cannot Be Edited


Created By: Shira Stamps On 02/10/2022 at 11:52 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: ANTELOPE VALLEY FOUNDATION, INC.
FACILITY NUMBER: 197603228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087(g) Buildings and Grounds
Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that Licensee did not keep cleaning solutions inaccessible to clients in care. LPA observed a cleaning solution sitting on the kitchen counter and in the first floor bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2022
Plan of Correction
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The Licensee agrees to provide training to all staff to keep disinfectants and cleaning solutions locked and inaccessible to clients. The Liceness will submit signatures of all staff that have completed this training.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022


LIC809 (FAS) - (06/04)
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