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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606493
Report Date: 04/03/2024
Date Signed: 04/03/2024 11:09:13 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/03/2024 11:09 AM - 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:
ADMINISTRATOR/
DIRECTOR:		KATHERINE JOY LARAFACILITY TYPE:
735
ADDRESS:39717 171 ST. E.TELEPHONE:
(661) 264-4214
CITY:PALMDALESTATE: CAZIP CODE:
93591
CAPACITY: 6CENSUS: 4DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ramiro LopezTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Lorena Casillas met with Direct Support Staff (DSP) Ramiro Lopez for an unannounced one (1) year Required visit for this facility.

LPA arrived at 09:30 am. LPA was greeted and granted access by DSP. LPA called Administrator and stated reason for the visit. The Administrator would not be able to attend, and designated DSP Ramiro Lopez to sign reports. All clients were in their day programs or out in the community. Entrance interview conducted.

A tour of the physical plant was conducted with DSP at 10:00 am. The facility has four (4) bedrooms and two (2) bathrooms. It is currently occupied by four (4) clients. LPA observed that the staff bedroom was locked, and clients do not have access to it.

LPA Casillas conducted an annual visit previously on 11/29/2023, therefore the Inspection Tool Kit was not used on this visit.

Infection control: LPA reviewed Infection control plan received on 07/01/22.

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 74°F. LPA observed staff and client files locked in a filing cabinet in the pantry. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:08 am.

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

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY CARE HOME #2
FACILITY NUMBER: 197606493
VISIT DATE: 04/03/2024
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Kitchen: LPA conducted a tour of the kitchen at 10:00 am 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. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was 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 knives locked in a drawer as well as 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. LPA observed another Fire extinguisher that was full and serviced on 5/2/23.

Bathrooms: LPA observed both bathrooms which contained wash your hands sign, hand soap, paper towels, and trash cans with lids. Hot water was tested at 10:05 am in the client bathroom and measured 118.6 degrees Fahrenheit.

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



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

Resident Files: LPA conducted a file review of resident records at 10:20 am.

Staff Files: LPA conducted a file review of staff records at 10:40 am.

Medications: At 11:00 am LPA and DSP reviewed medication and medication records for proper documentation.

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

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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