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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606626
Report Date: 06/15/2022
Date Signed: 06/16/2022 11:49:19 AM


Document Has Been Signed on 06/16/2022 11:49 AM - 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:ARAYATA ELDERLY CAREFACILITY NUMBER:
197606626
ADMINISTRATOR:NATIVIDAD ARAYATAFACILITY TYPE:
740
ADDRESS:44849 LOTUS LANETELEPHONE:
(661) 948-4985
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Natividad ArayataTIME COMPLETED:
12:00 PM
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At 10:30 a.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an annual inspection. Upon arrival, LPA was greeted by staff and staff granted access to home. LPA observed covid-19 signage posted outside the facility. LPA's temperature was taken and was asked to sign in the visitor’s log. Hand sanitizer and PPE supplies were readily available. LPA later met with the Administrator Natividad Arayata, and an entrance interview was conducted. The purpose of the visit was explained.

At 11:00 a.m. LPA initiated a physical plant tour. This is a six (6) bedroom three (3) bathroom Residential Care Facility for the Elderly. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of purchase of 4/16/2022. Smoke detectors and carbon monoxide monitors were observed to be functional. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Extra towels and linens were readily available. The backyard is clean, has a covered shaded area and there are no bodies of water.

No deficiencies issued during today’s visit. Report was signed and delivered by the Administrator. An exit interview was conducted with the Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
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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