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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606040
Report Date: 01/05/2024
Date Signed: 01/05/2024 02:31:41 PM

Document Has Been Signed on 01/05/2024 02:31 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: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:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Valeree ZepedaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit on 1/05/2024 and was greeted by the caregiver. LPA stated the purpose of the visit was to conduct an annual inspection. The caregiver confirmed there are four clients. The facility is licensed for two ambulatory and two non-ambulatory clients. The Assistant Administrator arrived at 9:20 am.

LPA Spaeth, the caregiver and Assistant Administrator toured the location at 9:25 am until 10:45 am.

Common Areas – LPA observed the living room contained comfortable seating and a television. The dining room area is furnished with a dining room table and chairs.

Garage – The garage was locked and contained the washer and dryer, emergency food, an additional refrigerator, the fire extinguisher and additional PPE.

Closet – The closet at the entrance to the property was locked and contained cleaning solutions.

Kitchen – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food items. The medications and the knives were locked in a cabinet. A fire extinguisher is located in the kitchen.

Hot Water Temperature – LPA tested the water temperature at 9:25 am which was 118.9 degrees F.


Resident Bedrooms - There are four resident bedrooms which are furnished with a bed, linens, night stand, chest of drawers and a closet.

Bathroom – There are two bathrooms in the facility which contained hand soap, paper towels and a trash can.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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: LORRAINE'S QUALITY HOMES
FACILITY NUMBER: 197606040
VISIT DATE: 01/05/2024
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Backyard - Comfortable outdoor seating is provided for the residents. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The detectors were tested at 9:35 am and were operable.

LPA Spaeth viewed residents' records at 10:00 am until 10:25 am. LPA reviewed staff records at 10:30 am until 10:45 am. LPA observed the P&I at 10:45 am until 10:52am. LPA reviewed resident medications at 10:52 am until 11:10 am.

There are no deficiencies to report. The exit interview was conducted, and a copy of the signed report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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