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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606435
Report Date: 12/07/2022
Date Signed: 12/07/2022 10:47:17 AM

Document Has Been Signed on 12/07/2022 10:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WESTSIDE VILLAFACILITY NUMBER:
197606435
ADMINISTRATOR:MEYNARD H. EBREOFACILITY TYPE:
740
ADDRESS:2044 W. AVENUE H6TELEPHONE:
(661) 729-5324
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 3DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Merlina EbreoTIME COMPLETED:
11:00 AM
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On 12/07/2022 at 9:30 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA was greeted by Staff #1 (S1) who was wearing a mask and granted access. S1 took LPA temperature S1 called the Administrator Merlina Ebreo to inform them LPA was here. Merlina met us shortly after. LPA explained the reason for the visit. LPA reviewed the Mitigation Plan approved 02/07/2021. The inspection tool was used to complete the visit.

At 9:37 a.m. LPA began a physical plant tour of the facility and the following was observed:

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Cleaning solutions are locked under the sink. Knives are kept locked in a kitchen drawer inaccessible to residents. LPA observed 2-day perishable and 7-day non-perishable supply of food. The fire extinguisher was observed by the kitchen and was last serviced on 11/25/2022.

Dining / Living Area: The dining and living area were well lit, clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area is not in use. LPA observed proper Covid-19 signs posted through out the facility. LPA observed the thermostat at a comfortable temperature of 75°F.

Bedrooms: There are four (4) bedrooms designated for resident use. One (1) out of the four (4) rooms is currently vacant. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens.

Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in a resident's bedroom for private use. The other main bathroom is accessible to all the residents. Both bathrooms were well lit, clean, had grab bars, had hand washing signs, nonskid mats and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels. At approximately 10:00 a.m. water temperature in the main bathroom was measured at 119.3°F.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WESTSIDE VILLA
FACILITY NUMBER: 197606435
VISIT DATE: 12/07/2022
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Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gate on side of the house was closed but unlocked. There is a covered patio to provide shade and appropriate outdoor seating for residents. LPA observed three (3) sheds in the backyard three (3) of three (3) are being used for storage.

Laundry Room: Laundry room is kept locked. LPA observed a washer and dryer that appeared operative. Detergents are kept in a cabinet above the washer and dryer.

Medications/ Resident file: LPA observed, resident medications looked in a closet by the kitchen inaccessible to residents. Resident and staff files locked in the administrators office inaccessible to residents.

LPA observed smoked alarms through out the facility. At 10:11 a.m. all smoke alarms were tested and functioned properly. LPA observed one carbon monoxide detector in the hallway and it appeared to be functioning. Administrator states the facility has enough PPE for 30 days.



No deficiencies were observed during todays visit and the facility is currently following their infection control plan.

Exit interview conducted and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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