197606626-7-8-2024-31-AS-ERIS-D6YRP7-20240708131129

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606626
Report Date: 07/08/2024
Date Signed: 07/08/2024 01:11:53 PM

Document Has Been Signed on 07/08/2024 01:11 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ARAYATA ELDERLY CARE		FACILITY NUMBER:	197606626
ADMINISTRATOR:	NATIVIDAD ARAYATA		FACILITY TYPE:	740
ADDRESS:	44849 LOTUS LANE		TELEPHONE:	(661) 948-4985
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	07/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Natividad Arayata		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/08/24 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by caregiver. Caregiver contacted the administrator and informed them LPA was at the facility. Administrator, Natividad Arayata met LPA shortly after. LPA Rios explained the purpose of the visit. This is a six (6) bedroom three (3) bathroom Residential Care Facility for the Elderly. Facility has an approved fire clearance for 6 bedridden residents for a total capacity of 6. At 9:45 a.m. LPA conducted a physical plant tour to ensure the health and safety of the residents in care. The following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen and medications were observed locked in a kitchen cabinet. Bedrooms: There were six (6) bedrooms of which five (5) are designated for residents' use and one (1) is shared. Four of the bedrooms are currently occupied. One (1) room is currently vacant. Rooms occupied by residents were properly furnished with appropriate bedding, linens, sufficient lighting and required furniture. Hallway closet by the bedrooms was observed to store extra linens. The facility keeps a comfortable temperature of 76 degrees Fahrenheit. Bathrooms: There are three (3) bathrooms. One (1) is located in the shared bedroom. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) bathroom at 10:22 a.m. and read 111.1 degrees Fahrenheit within compliance. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARAYATA ELDERLY CARE	FACILITY NUMBER: 197606626
	VISIT DATE: 07/08/2024

NARRATIVE

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Common Areas: These included the living areas and dining area. The common areas were clean, clear of clutter and properly furnished. Dining table and couches sit the capacity of the facility. Living area has a fire place secured with a screen. The auditory alarms on all exit doors were on and functional at the time of the visit. LPA observed two facility telephones operational.

The smoke alarms are hard wired and interconnected. Administrator tested the smoke detectors and carbon monoxide detector at 10:37 p.m. and they were observed to be functioning properly. Fire door closed automatically when smoke alarm went off. The fire extinguisher is located in the kitchen and was observed fully charged with purchase date 07/08/2024.

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards. There is a shaded area for residents. LPA observed a locked shed used for storage. No bodies of water observed.

Garage/Laundry: The laundry room is kept locked and inaccessible to residents in care. Detergents and cleaning products are kept in the laundry room locked. The locked laundry leads to the garage which is also inaccessible to residents.

Staff Files and Facility File: At 10:43 a.m. LPA also conducted a file review of staff records and facility records to insure forms and training are up to date and in compliance with licensing forms.

Resident Files: At 11:17 a.m. LPA conducted a file review of five (5) out 0f five (5) resident records to insure compliance of licensing forms.

Medications: At 12:00 p.m. Medication and Medication Records were reviewed for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during todays visit. Exit Interview Conducted. A copy of the report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC809 (FAS) - (06/04)

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