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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606435
Report Date: 12/11/2024
Date Signed: 12/11/2024 12:14:40 PM

Document Has Been Signed on 12/11/2024 12:14 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WESTSIDE VILLAFACILITY NUMBER:
197606435
ADMINISTRATOR/
DIRECTOR:		MEYNARD H. EBREOFACILITY TYPE:
740
ADDRESS:2044 W. AVENUE H6TELEPHONE:
(661) 729-5324
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Merlina EbreoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 12/11/2024 at 9:30 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. Upon entry LPA observed appropriate postings on the facility walls.

At 9:36 a.m. LPA began a physical plant tour of the facility and the following was observed:

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 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. Two (2) out of the four (4) rooms are 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. Bathrooms were well lit, clean, had grab bars, 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 was taken measured at between 118 to 120°F, within regulation.
Laundry Room/Garage: 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. The garage is through the laundry room. The garage has extra water and a deep freezer for the facility. (Continue to LIC809-C)
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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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: 12/11/2024
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(Continued from LIC809)

Surrounding Grounds: There is a covered patio to provide shade and appropriate outdoor furniture for residents. LPA observed three (3) sheds in the backyard used for storage and are kept locked. There were no visible hazards, and passageways were free from obstruction. Side gate on side of the house was closed but unlocked. There are no bodies of water.

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Knives are kept locked in the medication closet, 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 11/25/2024.

Resident/Staff files: At approximately 10:13 a.m. LPA reviewed two (2) out of two (2) resident records and reviewed three (3) staff records to insure compliance with licensing forms and updated training for staff. LPA reviewed the facility's Emergency Disaster Plan (LIC610E), Personnel Report (LIC500), Earthquake and Fire Drills and Certification of Liability Insurance,

Medications: Centrally stored medications are maintained in a locked closet. Centrally Stored Medication And Destruction Records were reviewed for proper documentation.

LPA observed smoke detectors through out the facility that are hardwired and interconnected. At 11:08 a.m. the administrator tested a smoke detector and smoke detectors were observed to be functioning properly. LPA observed two carbon monoxide detector one (1) the hallway and another in the kitchen that appeared to be functioning.



No deficiencies were observed during todays visit. Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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