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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606493
Report Date: 03/16/2022
Date Signed: 03/16/2022 12:49:10 PM

Document Has Been Signed on 03/16/2022 12:49 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:ANTELOPE VALLEY CARE HOME #2FACILITY NUMBER:
197606493
ADMINISTRATOR:KATHERINE JOY LARAFACILITY TYPE:
735
ADDRESS:39717 171 ST. E.TELEPHONE:
(661) 264-4214
CITY:PALMDALESTATE: CAZIP CODE:
93591
CAPACITY: 6CENSUS: 4DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marie BruTIME COMPLETED:
12:45 PM
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LPA Spaeth conducted an unannounced visit and arrived at 12:00 noon. LPA Spaeth was greeted by Administrator Marie Bru. LPA observed the COVID signs on the door and the Administrator was wearing a mask. Administrator confirmed there are four residents and all four residents were out of the facility during the annual visit. LPA observed Administrator was wearing a mask.

Upon entry, LPA's temperature was recorded and LPA observed the sign in station with thermometer, hand sanitizer, sign in sheet, and PPE supplies. LPA observed the facility was neat and clean. The living room contained comfortable seating along with a television. The kitchen pantry was well stocked with a seven day supply of canned goods. The refrigerator contained fresh vegetables, dairy products, and frozen vegetables and meats. The pantry contained a locked file cabinet which contained the residents' medications. The kitchen sink contained wash your hands sign, hand soap, paper towels and a covered trash can. LPA observed there were no knives in the kitchen but are locked in the staff room. LPA confirmed the staff room was locked;. The hallway closet contained cleaning supplies, laundry detergent and a 90 day supply of PPE.

The laundry area was in the hallway but the laundry detergent was safely locked. LPA observed the residents' rooms were neat and clean. All rooms contained beds, linens, lamp and night stand. The staff room was locked but LPA was escorted to the room and observed additional PPE and an additional freezer with frozen food.

The backyard area was accessible and is a safe area for residents to enjoy the outdoors.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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