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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606568
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:39:22 PM

Document Has Been Signed on 04/17/2024 03:39 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/
DIRECTOR:		VALEREE ZEPEDAFACILITY TYPE:
735
ADDRESS:2810 E. AVENUE R-15TELEPHONE:
(661) 264-0450
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 4DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Valeree ZepedaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by two caregivers. The Administrator, Valeree Zepeda arrived at 11:20 am. The staff confirmed there are four residents. The facility is licensed for four ambulatory and two non-ambulatory clients..

LPA Spaeth and the Administrator toured the facility at 11:30 am until 12:00 pm.

Living Room/Dining Room - When entering the facility, the living room is furnished with comfortable seating and a television. The dining room contains a dining room table and chairs. The medications are locked in a cabinet.

Kitchen - The facility contained a two day supply of perishable food and a seven day supply of non-perishable foods. The fire extinguisher is located in the kitchen and is operable.

Backyard- LPA observed comfortable furniture located in the backyard. The gate leading from the backyard to the front yard was not locked.

Garage//Washer & Dryer – The garage was locked and contained PPE, an additional refrigerator and the, washer/drye and laundry soap.

Hallway Closet - LPA observed the closet was locked and contained cleaning solutions.

Bathroom - LPA observed the bathroom contained hand soap and paper towels. The bathroom was nice and clean.

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SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 04/17/2024
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Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair.

Staff Room - LPA observed the staff room was locked. The knives are locked in the staff room.

Water Temperature: LPA tested the water temperature at 11:45 am and the temperature was 105.0 degrees F.

Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested at 11:50 am and were operable.

LPA Spaeth reviewed resident record at 12:00 pm until 12:20 pm. LPA also reviewed the staff records at 12:20 pm until 12:35 pm. LPA Spaeth reviewed the resident's medication at 12:30 pm until 12:45 pm.

There are no deficiencies at this time. Exit interview conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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