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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606436
Report Date: 07/10/2024
Date Signed: 07/10/2024 05:04:04 PM


Document Has Been Signed on 07/10/2024 05:04 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:AMERICANA RCFEFACILITY NUMBER:
197606436
ADMINISTRATOR:JAMES TRIPPFACILITY TYPE:
740
ADDRESS:40558 16TH ST. WESTTELEPHONE:
(661) 273-7349
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 3DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Teodoro TrippTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Licensee. LPA stated the purpose of the visit was to conduct an annual inspection. Staff confirmed there are three residents living at the facility. The facility is licensed for six non-ambulatory residents.

LPA and the caregiver toured the facility at 11:30 am until 12:15 am. LPA observed the facility was neat and clean.

Common Areas – LPA observed the living room contained seating and a television. The dining room contained dining room table and chairs..

Kitchen – LPAs observed the knives were locked in a kitchen drawer. The medications and first aid kit were locked in a kitchen cabinet. LPAs observed a two-day supply of perishable foods and a seven day supply of non-perishable foods. The cleaning solutions were safely locked underneath the kitchen sink and the kitchen was clean.

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

Bathroom - There are two bathrooms located in the facility. LPA Spaeth tested the water temperature at 12:30 pm which was 108 degrees F. The bathrooms contained hand soap, paper towels, slip resistant mats, trash can, and grab bars.

Staff Room - LPA observed the staff room which was locked.

Continued on 809-C

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMERICANA RCFE
FACILITY NUMBER: 197606436
VISIT DATE: 07/10/2024
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Smoke/Carbon Monoxide Detectors – The detectors were tested at 12:00 pm and observed were operable.

Backyard -LPA observed comfortable seating in the backyard. Upon entering the facility, LPA observed the front gate was not locked.



Garage - LPA observed the garage was locked and contained washer, dryer, emergency food, PPE, and laundry detergent.

Delayed Egress Devices – LPAs observed all delayed egress devices were functional. .

LPA reviewed residents' and staffs' records at 11:30 am until 12:30 pm. LPA reviewed the residents' medications and there were no issues.


There are no deficiencies to report at this time.



Exit interview conducted, A copy of the signed report was given to the Licensee
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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