<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606734
Report Date: 11/04/2024
Date Signed: 11/04/2024 10:46:13 AM

Document Has Been Signed on 11/04/2024 10:46 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:O-2 HOUSEFACILITY NUMBER:
197606734
ADMINISTRATOR/
DIRECTOR:		CLIFTON VON BUCKFACILITY TYPE:
735
ADDRESS:43956 21ST STREET WESTTELEPHONE:
(661) 729-1000
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 2DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:William Tan (Staff)TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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 11/04/2024 at approximately 8:30 a.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at this facility. LPA was greeted by staff #1(S1), William Tan, who granted access to the facility. S1 contacted the Administrator, Clifton VonBuck, LPA explained the reason for the visit. Clifton designated S1 to sign todays report. Administrator met LPA at the facility at 10:30 a.m.

At approximately, 8:48 a.m. LPA conducted a physical plant tour of the facility and the following was observed:

The facility is licensed for an Adult Residential Facility, and has an approved fire clearance for a capacity of 6 ambulatory clients.

Common Areas: LPA observed living room and dining room clean and clear of clutter. William was observed sweeping the floors. Furniture is in good repair. LPA observed a fireplace in the living room secured with a screen. Dining table and chairs sit the capacity of the facility.

Laundry / Garage: Laundry room is kept locked. Chemicals and detergents are kept locked in laundry room. LPA observed washer and dryer in use and operational. Client files are kept locked in the laundry room. Laundry room leads to garage. Garage is used to store facility supplies and is maintained locked.

Kitchen: LPA toured the kitchen area and observed seven day non-perishable supply of food and a two day perishable supply of food; properly stored. Cleaning products, knives and sharps were observed locked in a kitchen cabinet under the sink. A Fire extinguisher was observed by the kitchen to be fully charged with last serviced date 03/18/24. (Continued on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: O-2 HOUSE
FACILITY NUMBER: 197606734
VISIT DATE: 11/04/2024
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
26
27
28
29
30
31
32
(Continued from LIC809)

Smoke detectors / Carbon monoxide. Smoke detectors are hard wired and interconnected. At 9:04 a.m. S1 tested smoke detector and they were observed operational. Carbon monoxide detector was observed in the main entry by the kitchen and observed to be operational.

Bedrooms: There are three (3) bedrooms designated for clients. LPA observed rooms to be properly furnished with a night stand, chair, and sufficient lighting. Clients' beds and mattresses were observed in good repair with appropriate bedding. LPA observed cabinet by the bedrooms with extra linens.

Bathrooms: There is one (1) bathroom designated for clients. LPA observed the bathroom to be clean and in good repair. Bathroom was properly supplied with toilet paper, soap and an automatic hand dryer. The hot water temperature measured at approximately 9:06 a.m. and it read 113.5°F.



Surrounding Grounds: LPA toured the outside area of the facility. LPA observed a covered patio that provides shade for the clients and appropriate outdoor furniture. There is a hot tub emptied of water, that is not in use and is kept locked.

Client / Facility Records: At approximately 9:30 a.m. LPA reviewed two (2) of two (2) client files to insure compliance of licensing forms. LPA also conducted file review of two (2) staff records to insure forms and training are up to date and in compliance with licensing forms. LPA reviewed facility's staff schedule, bond and Emergency Disaster Plan (LIC610E).

Medications: LPA observed centrally stored medications in a locked file cabinet in the office area. At 10:15 a.m. Medications and Centrally Stored Medication Destruction Records (CSMDR) were reviewed. Facility also uses a Medication Administration Record (MAR).

Pursuant to Title 22 Division 6 Chapter 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit interview conducted and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2