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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606436
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:33:38 PM


Document Has Been Signed on 06/09/2022 04:33 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:AMERICANA RCFEFACILITY NUMBER:
197606436
ADMINISTRATOR:JAMES TRIPPFACILITY TYPE:
740
ADDRESS:40558 16TH ST. WESTTELEPHONE:
(661) 273-7349
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 5DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Johnny GaxiolaTIME COMPLETED:
04:00 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and was greeted by caregiver (S1). LPA observed S1 was wearing a mask and S1 requested LPA to sign in at the sign in station. LPA's temperature was recorded and LPA observed thermometer, additional masks, hand sanitizer, and sign in sheet were located at the front entrance.

LPA and S1 began tour at 2:35 pm. LPA observed the living room where three residents were watching television. The living room had adequate seating. LPA observed the four resident bedrooms. Room 3 contained a bed, linens, night stand, lamp and chair. The staff room was locked. Rooms 1 through 3 also contained the required furniture. LPA observed all four rooms have exit doors and the alarms for exiting the rooms were properly working.

The hallway closet contained linens including bath towels and bed linens. There are two bathrooms in the facility. Bathroom 1 contained hand soap, paper towels, and trash can. Bathroom 2 is connected to the master bedroom and currently being remodeled. LPA observed the Bathroom 2 will have a walk in shower in order to accommodate those residents who use a wheelchair. LPA observed a caregiver arrived to the facility at 3:00 pm and was wearing a mask.

LPA observed an adequate supply of PPE in storage along with the emergency supply of food and water. LPA observed these items were stored in the locked garage. The garage also contains the washer and dryer along with laundry detergent.

LPA was then escorted to the backyard and observed the gate was not locked. Upon entering the facility, LPA was escorted to the kitchen. LPA observed a four day supply of fresh fruits and vegetables in the refrigerator. The freezer section contained frozen meats. The pantry contained a seven-day supply of canned goods and other dry products such as pasta. LPA observed the medications were safely locked in a kitchen cabinet.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMERICANA RCFE
FACILITY NUMBER: 197606436
VISIT DATE: 06/09/2022
NARRATIVE
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LPA observed the cabinet underneath the sink was not locked. All cleaning supplies were stored in the cabinet. LPA explained to S1 that based upon the regulations, these items must be locked. At 2:35 pm LPA observed S1 placed a lock on the cabinet. The cleaning were safely locked in the cabinet as of 2: 40 pm.

Based upon LPA's observations, a deficiency is hereby issued. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/09/2022 04:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: AMERICANA RCFE
FACILITY NUMBER: 197606436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2022
Section Cited

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement is evidenced by:
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LPA Spaeth observed the cleaning solutions were not securely locked in the kitchen which poses an immediate health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
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