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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606493
Report Date: 01/28/2025
Date Signed: 01/28/2025 01:12:14 PM

Document Has Been Signed on 01/28/2025 01:12 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/
DIRECTOR:		KATHERINE JOY LARAFACILITY TYPE:
735
ADDRESS:39717 171 ST. E.TELEPHONE:
(661) 264-4214
CITY:PALMDALESTATE: CAZIP CODE:
93591
CAPACITY: 6CENSUS: 4DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Marie Lara BruTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Lorena Casillas met with Licensee, Marie Lara Bru for an unannounced one (1) year Required visit for this facility.

LPA arrived at 09:30 am. LPA was greeted and granted access by Licensee, Marie Lara Bru and LPA stated reason for the visit. All clients were in their day programs. Entrance interview conducted.

A tour of the physical plant was conducted with Licensee at 10:30 am. The facility has four (4) bedrooms and two (2) bathrooms. It is currently occupied by four (4) clients who stay in shared rooms. One (1) room is for staff use only. LPA observed that the staff bedroom was locked, and clients do not have access to it.

Infection control: LPA reviewed Infection control plan received on 07/01/22, to ensure that licensee was following current infection control recommendations.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. Dining table has enough space to seat all clients. The facility maintains a comfortable temperature at 72°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:55 am.

Hallway Closet: LPA observed the locked 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.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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: 01/28/2025
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Kitchen: LPA conducted a tour of the kitchen at 10:40 am and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. There is an extra freezer adjacent to the kitchen that contains additional food. Food storage and preparation areas care clean and inaccessible to pests. There is one (1) fire extinguisher located in the kitchen, one (1) in the hallway and one (1) near the pantry. The fire extinguishers were observed to be full and last serviced on 04/18/2024. The pantry contained a locked file cabinet which contained client medications. LPA observed there were no knives in the kitchen, they are locked in the staff room. LPA confirmed the staff room was locked but LPA was allowed entry to the room and observed knives locked in a drawer.

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 10:50 am in the client bathroom 118.6 degrees Fahrenheit.

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



Physical environment: LPA toured the outside area of the facility at 11:00 am. LPA observed appropriate outdoor furniture, with a shaded area for residents. No bodies of water on the premises.

Administrative: LIC500, Bond, Administrator Certificate, Liability Insurance and Client roster collected. Annual fees are current.

Client and Staff Files: LPA conducted a file review of client and staff records at 11:30 am.

Medications: At 12:35 pm LPA and Licensee reviewed medication and medication records for proper documentation.

Client and Staff Interviews: LPA was not able to interview clients as they are in day program. LPA was able to interview one (1) staff member that was in the facility.

No citations issued. Exit interview conducted and a copy of the report was provided to Licensee.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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