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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606734
Report Date: 11/03/2021
Date Signed: 11/03/2021 02:03:55 PM

Document Has Been Signed on 11/03/2021 02:03 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:O-2 HOUSEFACILITY NUMBER:
197606734
ADMINISTRATOR:CLIFTON VON BUCKFACILITY TYPE:
735
ADDRESS:43956 21ST STREET WESTTELEPHONE:
(661) 729-1000
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:William Tan - StaffTIME COMPLETED:
02:15 PM
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At 12:55 PM, Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff William Tan who granted access to the home. Administrator Clifton Von Buck was contacted by phone. The LPA spoke with the administrator and stated the purpose of the visit. The administrator stated he was out of town and was unable to meet the LPA at the facility. This is an four (4) bedroom, two (2) bathroom single story adult residential care facility. A physical tour was initiated at 1:10 pm and observed the following: Infection control: Some infection control signage was observed outside the home and inside the facility. LPA reminded administrator to include all necessary postings outside. Upon entrance, staff took LPA's temperature and was asked to sign-in the visitor’s log but was not asked any infection control questions. Hand sanitizer was available, and trash cans were observed to have closed tight fitting lids. Sufficient PPE supplies were observed. Food Inspection: 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 in locked cabinets in the kitchen area. Smoke detectors/carbon monoxide were located throughout the facility. At 1:15 PM, they were tested and are functional. Facility maintains a comfortable temperature of 71.0 F. Resident rooms: There are three (3) bedrooms designated for resident use, one (1) bedroom is designated for live-in staff. All bedrooms are properly furnished, clean, and have appropriate bedding and linens. Bathrooms: The hot water temperature measured at 113.5 F. Towels and washcloths are not shared. Extra towels and linens were readily available. Garage was attached to the home and is used for storage. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. No deficiencies cited. A copy of this report was provided. Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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