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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606435
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:55:55 AM

Document Has Been Signed on 01/23/2024 11:55 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:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Merlina EbreoTIME COMPLETED:
12:10 PM
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On 01/23/2024 at 9:20 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual Inspection. LPA was greeted by Staff #1 (S1) who granted access. S1 called the Administrator Merlina Ebreo to inform them LPA was at the facility. Merlina met LPA shortly after. LPA explained the reason for the visit. The inspection tool was used to complete the visit.

At 9:35 a.m. LPA began a physical plant tour of the facility and the following was observed:

Kitchen: LPA observed required postings upon entry. 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; properly stored. The fire extinguisher was observed by the kitchen fully charged with receipt of purchase on 11/08/2023.

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 was not in use and secured with a glass screen. LPA observed the thermostat at a comfortable temperature of 73°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. There are extra linens in a hallway closet.

Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in a resident's bedroom for private use. The main bathroom is accessible to all the residents.
(Continued on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WESTSIDE VILLA
FACILITY NUMBER: 197606435
VISIT DATE: 01/23/2024
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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, paper towels and toilet paper. At approximately 11:10 a.m. hot water temperature in the main bathroom was measured at 118.4°F.

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 and are kept locked.

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.

Resident/Staff files: At approximately 10:00 a.m. LPA reviewed three (3) staff records and three (3) out of three (3) resident records to insure compliance.

Medications: Centrally stored medications are maintained in a locked closet. Centrally Stored Medication And Destruction Records were reviewed for proper documentation. Medication records are maintained manually and facility maintains a Medical Administration Record (MAR).

LPA observed smoke alarms through out the facility. At 11:01 a.m. S1 tested smoke detector and were observed to function properly. LPA observed one carbon monoxide detector in the hallway and it appeared to be functioning.



No deficiencies were observed during todays visit. Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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