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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603228
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:01:11 PM

Document Has Been Signed on 12/16/2024 12:01 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANTELOPE VALLEY FOUNDATION, INC.FACILITY NUMBER:
197603228
ADMINISTRATOR/
DIRECTOR:		DAVENPORT, GAMZEFACILITY TYPE:
735
ADDRESS:36448 RODEO STREETTELEPHONE:
(661) 533-0974
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 4DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Gamze Davenport- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 12/16/2024 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by Program Manager, Robert Davenport. LPA stated the reason for their visit. The Administrator, Gamze Davenport, was called and arrived shortly after to assist with today’s visit.

LPA asked for census, staff, and resident files. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted:

There is only one entrance being utilized at the facility. The facility is a two (2) story building with six (6) bedrooms and three (3) bathrooms currently occupying four (4) residents. Two (2) rooms are designated staff rooms only. The facility is fire cleared for six (6) ambulatory Clients.

Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA observed required postings such as Emergency Disaster Plan, Facility License, Personal Rights and Rights of Individuals with Developmental Disabilities located in downstairs hallway leading towards bedrooms.
Smoke detectors and carbon monoxide observed to be working properly and were tested.

Both living room and dining room observed to be neat, clean, and organized. Both observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 73°F. Fire extinguishers located leading towards kitchen purchased on 11/16/2024. Electric fireplace observed to be covered inaccessible to clients.

(continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY FOUNDATION, INC.
FACILITY NUMBER: 197603228
VISIT DATE: 12/16/2024
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Upstairs: LPA observed four (4) bedrooms upstairs and one (1) bathroom. Two (2) rooms were staff personal rooms which were locked inaccessible to clients. The clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Sufficient availability of clean lien stored in hallway cabinet. An additional common area located upstairs with various exercise equipment. All equipment observed to be working and in proper condition.

The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Knives/sharps, toxins, and cleaning solutions observed to be locked in downstairs hallway storage room inaccessible to clients. Stove observed to be working and in proper condition. An additional common area located near the kitchen and observed to properly furnished and in good repair.

The backyard of the facility is equipped with a designated shaded area with outdoor furniture for clients. There is no body of water in this facility.

The laundry room can be accessed from the inside of the kitchen leading into the garage. Laundry detergents, cleaning agents, and other toxins are stored in a locked storage room in hallway inaccessible to clients.

LPA observed two (2) additional client bedrooms downstairs. The clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Clients have sufficient personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at 110.8°F. Towels and washcloths are not shared.

Medications: LPA observed medication in downstairs living room. Medication stored in a locked cabinet and inaccessible to clients. Medication usage recorded and stored properly. LPA along with Administrator Davenport conducted a review of the medication to ensure compliance. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual.

Clients’ records: LPA conducted a complete file review of client records. Client records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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