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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606708
Report Date: 10/09/2024
Date Signed: 10/09/2024 03:12:26 PM

Document Has Been Signed on 10/09/2024 03:12 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 FACILITY 2FACILITY NUMBER:
197606708
ADMINISTRATOR/
DIRECTOR:		DON TURNERFACILITY TYPE:
735
ADDRESS:37632 DALZELL STREETTELEPHONE:
(661) 265-7423
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 4DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Valeree ZepedaTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 10/09/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by the Administrator, Valeree Zepeda. The facility is licensed as an adult residential facility to serve four ambulatory clients.

LPA and the Administrator began the tour of the facility at 9:00 to 9:30 am. LPA observed the following:

Living Room– LPA Spaeth observed the living room contained comfortable seating.

Kitchen/Dining room - The dining room and kitchen are combined. The dining area contained a dining room table and seating. LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The knives and medications were locked in a cabinet. The fire extinguisher is located in the kitchen.

Hallway Closet - The closet was locked and contained the cleaning solutions and hygiene items.

Garage/Office - The garage was locked and contained an additional refrigerator and freezer, laundry soap, washing machine, dryer, client hygiene items, additional PPE, emergency food and cleaning solutions.

Bathrooms – LPA Spaeth observed the bathrooms contained hand soap, paper towels, and a trash can. LPA tested the water temperature at 10:29 am and was 110 degrees F.

Bedrooms – LPA Spaeth observed the bedrooms contained bed, linens, night stand, chair, chest of drawers, and a night lamp.

Cont'd 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMDALE CARE FACILITY 2
FACILITY NUMBER: 197606708
VISIT DATE: 10/09/2024
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Backyard – LPA Spaeth observed comfortable seating in a shaded area. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 11:09 am and are operational.

LPA reviewed client files at 9:40 am until 10:05 am. LPA reviewed staff files at 10:05 am until 10:35 am. LPA reviewed P&I at 10:35 am until 10:40 am. LPA reviewed client medications at 11:10 am until 11:15 am.

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: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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