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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606568
Report Date: 06/11/2023
Date Signed: 06/11/2023 12:49:28 PM

Document Has Been Signed on 06/11/2023 12:49 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.ASC, 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:
06/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Socorro Caballero - StaffTIME COMPLETED:
12:45 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with Staff Socorro Caballero and explained the purpose of the visit. Staff called the administrator and designated Ms. Caballero to sign the report. LPA observed that all the residents were present at the facility.

At 9:23 AM, LPA conducted physical plant tour inside and out. During the tour, LPA observed that the facility has four (4) bedrooms and two (2) bathrooms. One (1) bedroom and one (1) bathroom is designated for staff use. There is no body of water in the facility.

Infection control: The facility has submitted and approved Mitigation Plan and Infection Control plan on file. The main door is the only entrance being utilized at the facility. There is a sign on the door that everyone entering at the facility must wear mask. Screening area is located in immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Hand washing sign are posted on the bathroom.

Bedrooms were toured and observed to be clean and appropriately furnished.
Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at of 108.7°F.
Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All disinfectants, cleaning solutions and laundry detergents were observed to be locked in the closet on the hallway. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2023
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMDALE CARE FACILITY
FACILITY NUMBER: 197606568
VISIT DATE: 06/11/2023
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(continued from LIC 809)

Food. The facility is observed to have sufficient food supply for clients, both perishable and non-perishable. Temperature of facility wall thermostat was set at 75.0°F and observed to be within the required range.

Fire extinguisher was observed to be located by the kitchen. Extinguisher was observed to be operable and last bought on 05/03/23. Fire alarms are interconnected and observed to be operational. There was a carbon monoxide installed in the facility.

Medication were observed to be locked, inaccessible and stored in the cabinet near the dining room. Medication records and procedures reviewed with staff. There were two (2) complete first aid kits located in the supply room inside the staff room closet. Knives and sharps are locked and secured in the closet inside the staff room.

Garage is attached to the house and observed to be locked and inaccessible to clients. Garage is also used as laundry room and frozen food storage.

Client records were also reviewed. Clients record appeared to be complete and current.

Staff records were also reviewed. Staff present has criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate observed to be current.

Disaster drills was last conducted on 03/09/23. Required posting observed in facility (complaint hot line poster).

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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