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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606493
Report Date: 11/29/2023
Date Signed: 11/29/2023 01:55:16 PM

Document Has Been Signed on 11/29/2023 01:55 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.RO, 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: 2DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Marie BruTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Marie Bru for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:50 am. LPA received no answer at the door. LPA called Administrator and stated reason for the call and visit. Administrator stated that she was in court with a client, but they were finished and would be headed to the facility. Administrator arrived at 11:40 am. All clients were in their day programs or out in the community. Entrance interview conducted.

A tour of the physical plant was conducted with the Administrator at 11:50 am. The facility has four (4) bedrooms and two (2) bathrooms. It is currently occupied by two (2) clients. LPA observed that staff bedroom was locked, and clients do not have access to it.

Infection control: LPA reviewed facility infection control plan received on 07/01/22, to make sure licensee is following current infection control recommendations.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 68°F. LPA observed staff and client files locked in the filing cabinet. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 12:00 pm.

Continued...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY CARE HOME #2
FACILITY NUMBER: 197606493
VISIT DATE: 11/29/2023
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Kitchen: LPA conducted a tour of the kitchen at 12:05 pm and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Fire extinguishers were observed to be full and last serviced on 05/02/2023. The pantry contained a locked file cabinet which contained the residents' medications. LPA observed there were no knives in the kitchen, but they are locked in the staff room. LPA confirmed the staff room was locked but LPA was escorted to the room and observed additional PPE and an additional freezer with frozen food.

Hallway Closet: LPA observed the hallway closet contained cleaning supplies, laundry detergent and a supply of PPE. LPA observed the laundry area to be in the hallway, but the laundry detergent was safely locked in the closet.

Bathrooms: LPA observed client bathroom which contained wash your hands sign, hand soap, paper towels, and trash cans with lids. Hot water was tested at 12:08 pm in the client bathroom measuring at 118.6 degrees Fahrenheit.

Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client.



Physical environment: LPA toured the outside area of the facility at 12:10 pm. LPA observed appropriate outdoor furniture, with a shaded area for residents. No bodies of water on the premises.

Administrative: LIC500 and client roster collected. Annual fees are current.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms at 12:15 pm.

Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and in compliance at 12:30 pm.

Continued....
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY CARE HOME #2
FACILITY NUMBER: 197606493
VISIT DATE: 11/29/2023
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Staff Interviews: At 12:45 pm LPA interviewed staff.

Client Interviews: No client interviews at this time as they were out in the community.

Medications: At 1:05 pm LPA and Administrator reviewed medication and medication records for proper documentation.

There are no deficiencies to report and no citations to be issued. Exit interviewed conducted and a copy of the report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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