197606436-9-14-2023-31-AS-MSPH-CVNSWT-20230914141450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606436
Report Date: 09/14/2023
Date Signed: 09/14/2023 02:15:10 PM

Document Has Been Signed on 09/14/2023 02:15 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 RCFE		FACILITY NUMBER:	197606436
ADMINISTRATOR:	JAMES TRIPP		FACILITY TYPE:	740
ADDRESS:	40558 16TH ST. WEST		TELEPHONE:	(661) 273-7349
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 6	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Johnny Gaxiola		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the two caregivers. LPA stated the purpose of the visit was to conduct an annual inspection. Staff confirmed there are six residents living at the facility. The facility is licensed for six non-ambulatory. Staff called the Administrator at 11:30 am who stated caregiver may sign the report LPAs toured the facility with the caregivers 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. 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 and a closet. Bathroom - There are two bathrooms located in the facility. LPA Spaeth tested the water temperature at 11:45 am which was 105 degrees F. Both bathrooms contained hand soap, paper towels, slip resistant mats, trash can, and grab bars. Staff Room - LPA observed the staff room which locked.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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: 09/14/2023

NARRATIVE

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Smoke/Carbon Monoxide Detectors – The detectors were tested at 1:30 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. .

LPAs reviewed residents' and staffs' records at 12:20 pm until 1:10 pm.

Residents’ medications were reviewed at 1:10 pm until 1:30 pm.

There are no deficiencies to report at this time.

Exit interview conducted, A copy of the signed report was given to caregiver

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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