<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603228
Report Date: 12/13/2023
Date Signed: 12/13/2023 04:06:55 PM

Document Has Been Signed on 12/13/2023 04:06 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
WOODLAND HILLS S.ASC, 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:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Robert DavenportTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 12/13/2023. LPA was greeted by the house manager. The Administrator arrived at 10:20 am. The facility is licensed for six ambulatory clients and there are three clients living in the facility.

LPA Spaeth and the House Manager began the tour at 9:55 am until 10:23 am. LPA observed the following:

Common areas – The living and dining room are combined and contained dining room table, chairs, and a couch. A locked cabinet in the living room contained the residents' medications.

Kitchen/Family Room – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food. There were no cleaning solutions stored underneath the kitchen sink. Fire extinguishers were located near the kitchen area and were operable. The family room contained comfortable seating.



Laundry Area - The laundry room was locked and contained the washer and dryer.

Garage – The garage was locked and contained emergency food and water.

Hallway Closet - The hallway closet was locked and contained the first aid kit and hygiene items on the top shelf and the cleaning supplies were stored at the bottom of the closet.

Resident Rooms - LPA observed the resident rooms contained bed, linens, night stand, lamp, closet and chest of drawers.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY FOUNDATION, INC.
FACILITY NUMBER: 197603228
VISIT DATE: 12/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Bathrooms – LPA observed the two bathrooms. Both bathrooms contained hand soap, paper towels, slip resistant mats and covered trash cans. The water temperature was tested in Bathroom 1 at 10:25 am and was 110 degrees F.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 10:33 am and were operable.

Backyard - LPA observed the backyard which has a shaded area. The gate leading from the backyard to the front yard was not locked.

LPA reviewed client records at 10:30 am until 10:50 am and staff records at 10:50 am until 11:20 am.
LPA reviewed P&I records at 11:30 am until 11:45 am

There are no deficiencies to report at this time.

Exit interview conducted and a copy of the signed report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2