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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605091
Report Date: 03/18/2022
Date Signed: 03/18/2022 02:35:25 PM


Document Has Been Signed on 03/18/2022 02:35 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:YONG CARE HOMEFACILITY NUMBER:
197605091
ADMINISTRATOR:GARY JOHNSONFACILITY TYPE:
740
ADDRESS:1539 W. AVENUE L-12TELEPHONE:
(661) 916-9351
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 2DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Gary JohnsonTIME COMPLETED:
02:30 PM
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LPA Spaeth conducted an unannounced visit and was at met the front door by Administrator Gary Johnson who confirmed there are two residents in the facility. LPA observed Administrator and wife Yong who is the caregiver were both wearing a mask. LPA's observed the sign in station which contained hand sanitizer, masks and additional PPE supplies at the front door. LPA's temperature was recorded.

LPA began the tour at 1:35 and observed an ample supply of fresh vegetables and frozen meats in the refrigerator. There was an additional freezer in the kitchen and LPA observed frozen vegetables and meats stored in the freezer. LPA observed wash your hands sign, hand soap and paper towels in the kitchen. LPA observed the knives were locked in a kitchen drawer and the medications were locked in a kitchen cabinet.

LPA observed the resident's rooms and observed both rooms contained bed, linens, night stand, and lamp. There are two rsident bathrooms in the facility and both contained hand soap, paper towels, wash hands sign and trash can.

LPA was escorted outside and observed the backyard contained comfortable seating and there were no safety issues such as gardening tools in the backyard. LPA observed the staff room was locked and the staff bathroom was located on the other side of the facility. LPA confirmed there is a 90 day supply of PPE.

There are no deficiencies to report. Exit interview conducted, and a copy of the signed report was given to the Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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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