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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606568
Report Date: 09/21/2021
Date Signed: 09/21/2021 01:03:11 PM

Document Has Been Signed on 09/21/2021 01:03 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:PALMDALE CARE FACILITYFACILITY NUMBER:
197606568
ADMINISTRATOR:MYRNA DELA CRUZFACILITY TYPE:
735
ADDRESS:2810 E. AVENUE R-15TELEPHONE:
(661) 265-0450
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Valeree Zepeda, AdministratorTIME COMPLETED:
01:20 PM
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At 10:00am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff, Socorro Caballero, who granted access to the facility. At approximately, 10:10am physical tour was conducted with the staff and shortly after the Administrator arrived. LPA observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 02/13/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for clients and staff. LPA advised the administrator to review their mitigation plan with all staff to ensure all visitors are thoroughly screened upon entry. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: At approximately, 10:15am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharp objects were observed in a portable, locked toolbox and were kept in staff room inaccessible to clients in care. The fire extinguisher is located in the kitchen and was observed to be fully charged and was bought on 03/09/2021

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:45am they were tested and observed to be operational.

Bedrooms: There are three (3) bedrooms designated for clients' use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMDALE CARE FACILITY
FACILITY NUMBER: 197606568
VISIT DATE: 09/21/2021
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Bathrooms: At 10:00am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 112°F. LPA observed appropriate grab bar and had non-skid mat.
Common Areas: The facility maintains a comfortable temperature at 75°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. All cleaning supplies are stored in a hallway closet and were observed locked and inaccessible to clients.
Outside areas: At approximately, 11:10am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water
The garage: Laundry area is located in an attached garage and kept locked and inaccessible to clients. Extra PPE supplies and food storage was also observed.
Medications: At approximately, 10:05am LPA observed medications are centrally stored and locked in the cabinet, by the kitchen area, and inaccessible to clients in care.

Administrative: LPA collected Certificate of Liability Insurance, Administrator Certificate and LIC.500. Annual fees are current.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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