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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606568
Report Date: 03/07/2022
Date Signed: 03/07/2022 12:58:23 PM

Document Has Been Signed on 03/07/2022 12:58 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:VALEREE ZEPEDAFACILITY TYPE:
735
ADDRESS:2810 E. AVENUE R-15TELEPHONE:
(661) 264-0450
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 4DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Valeree Zepeda, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Valeree Zepeda for an unannounced one (1) year Required visit for this facility. LPA arrived at 11:50 am and was greeted by caregiver, Soccoro Caballero The Administrator arrived at 11:53am, and LPA informed the Administrator of the purpose of the visit.

Infection control: LPA Stamps reviewed facility mitigation plan (approved on 02/13/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the Caregiver. Sink was available to wash hands.

A tour of the physical plant was conducted with the Administrator at 11:55 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. One (1) bedroom and one (1) bathroom are designated for staff use only. The facility is Fire Cleared for four (4) ambulatory and two (2) non ambulatory. All clients were observed to be in the dining area eating lunch.

Food Inspection
LPA conducted a tour of the kitchen around 11:57 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 care clean and inaccessible to pests. LPA observed an extra refrigerator and deep freezer in the garage.

Resident Rooms
LPA observed staff washing client’s bedding the time. LPA observed appropriate bedding sheets and blankets in the hallway closet. There is a nightstand and sufficient lighting for each resident.

Bathrooms
At 12:00 pm LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted will be posted in the client’s bathroom. Hot water was tested at 12:04 pm and measured within regulation at 113.8 degrees F.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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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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: 03/07/2022
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Laundry/Garage
At 12:12 pm, LPA observed the laundry room located in the garage. LPA observed the chemicals/hazardous items locked in the staff room inaccessible to clients in care. The Garage is attached to the facility and currently being used for extra storage for diapers, PPE, and refrigerator and deep freezer.

Physical environment
LPA toured the outside area of the facility at 12:14 pm. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

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 67°F. The smoke detectors and carbon monoxide detector were tested and observed to be operational at 12:50 pm. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 03/09/21. LPA observed the medications in a locked cabinet and inaccessible to client’s in care.

Administrative: LPA collected the client roster and the LIC.500. Annual fee is current.


An exit interview was conducted, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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