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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606040
Report Date: 11/16/2022
Date Signed: 11/16/2022 12:57:23 PM

Document Has Been Signed on 11/16/2022 12:57 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:LORRAINE'S QUALITY HOMESFACILITY NUMBER:
197606040
ADMINISTRATOR:MANUEL MENDOZAFACILITY TYPE:
735
ADDRESS:2641 EAST AVENUE Q-4TELEPHONE:
(661) 947-8841
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 4DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Valeree Zepeda/ Admin AssistantTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct an Infection Control Annual. The LPA was greeted by facility staff, who were observed wearing masks. The LPA had his temperature taken and COVID-19 questions were asked.

The LPA was able to tour the home and tested all smoke alarms and carbon monoxide detectors, which functioned properly. The fire extinguisher was observed in the kitchen and was purchased in 12/21. The inspection tool was used to conduct this annual.

The facility is currently following their infection control plan and no deficiencies were observed during the visit.
Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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