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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606708
Report Date: 10/04/2022
Date Signed: 10/04/2022 11:08:54 AM

Document Has Been Signed on 10/04/2022 11:08 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:PALMDALE CARE FACILITY 2FACILITY NUMBER:
197606708
ADMINISTRATOR:DON TURNERFACILITY TYPE:
735
ADDRESS:37632 DALZELL STREETTELEPHONE:
(661) 265-7423
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 4DATE:
10/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Valeree Zepeda, AdministratorTIME COMPLETED:
11:20 AM
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Licensing Program Analysts (LPA) Shira Stamps met with Administrator Valeree Zepeda for an unannounced one (1) year Required visit for this facility.

Infection control: LPA 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 and asked all infection control questions. LPA was signed-in and sanitizer was available.

LPA arrived at 9:55am and was greeted by caregiver. One (1) client was observed i to be in their room resting. The Administrator arrived at 10:10 am. LPA informed the Administrator of the purpose of the visit.

A tour of the physical plant was conducted with the Administrator at 10:20am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility has awake staff at night. The facility is Fire Cleared for four (4) ambulatory.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client.

Bathrooms
At 10:26 am LPA observed all bathrooms to have grab bars and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 116.7 degrees F.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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 2
FACILITY NUMBER: 197606708
VISIT DATE: 10/04/2022
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Food Inspection
LPA conducted tour at the kitchen around 10:30 am 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.

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 74°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:38 am. There is one (1) fire extinguishers located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 05/24/22. LPA observed all knives and sharp objects double locked, and medications inaccessible to clients in care in the locked office cabinet.

Garage/Laundry
LPA observed the garage to be attached to the facility and currently being used for extra storage, extra refrigerator, and freezer. The PPE supplies and laundry area are also located in the garage. LPA observed the office located in the garage, to have client and staff files. The office is to remain locked at all times.

Physical environment
LPA toured the outside area of the facility at 10:35 am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients and a locked shed. No bodies of water on the premises.

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

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: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC809 (FAS) - (06/04)
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