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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605632
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:17:33 PM

Document Has Been Signed on 10/25/2023 04:17 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:TURNER'S RESIDENTIAL FACILITYFACILITY NUMBER:
197605632
ADMINISTRATOR:VALEREE ZEPEDAFACILITY TYPE:
735
ADDRESS:2923 EAST AVENUE R-10TELEPHONE:
(661) 480-7297
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 4DATE:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Valeree ZepedaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by the caregiver. The Administrator arrived at 1:00 pm. The facility is licensed as an adult residential facility to serve four ambulatory residents and staff confirmed there are four residents living in the facility.

LPA and Administrator began the tour of the facility at 1:10 pm until 1:25 pm. LPA observed the following:

Living Room– LPA Spaeth observed the living room comfortable seating and a television.

Kitchen/Dining room - The dining room and kitchen are combined. LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The fire extinguisher is located in the kitchen. LPA observed the knives, residents' files, and residents' medications were locked in a cabinet in the dining room. The dining area contained a dining room table and chairs The water temperature was tested at 1:30 pm and the temperature was 120.0 F.

Bathroom – LPA Spaeth observed the bathroom contained hand soap, paper towels, and a trash can.

Bedrooms – LPA Spaeth observed there are two client bedrooms in the facility. The bedrooms contained bed, linens, night stand,chair, and night lamp.

Laundry Room – LPA Spaeth observed the laundry room was locked and contained a washer and dryer.

Garage - LPA observed the cleaning solutions, PPE, and emergency water.

cont'd 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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: TURNER'S RESIDENTIAL FACILITY
FACILITY NUMBER: 197605632
VISIT DATE: 10/25/2023
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Backyard – LPA Spaeth observed comfortable seating in a shaded area. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke detectors were tested at 1:45 pm. The smoke/carbon monoxide detectors are operational.

LPA reviewed client's P&I at 1:45 until 1:55 pm. LPA viewed clients files at 1:55 pm until 2:15 pm. LPA Spaeth conducted the medication review at 2:15 pm until 2:40 pm. LPA reviewed staff records at 2:40 pm until 3:00 pm.

There are no deficiencies at this time.



Exit interview conducted, and a copy of the signed report was given to caregiver.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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