197606773-10-12-2021-31-AS-SSTS-C7QS8E-20211012133900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606773
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:39:40 PM

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:	BEST ELDER CARE III		FACILITY NUMBER:	197606773
ADMINISTRATOR:	FABIOLA IGID		FACILITY TYPE:	740
ADDRESS:	38648 CORTINA WAY		TELEPHONE:	(661) 274-2413
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY:	6	CENSUS: 5	DATE:	10/12/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Fabiola Igid, Administrator		TIME COMPLETED:	02:00 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	Licensing Program Analysts (LPAs) Shira Stamps and Angela Panushkina, met with administrator Fabiola Igid for a One (1) year Required visit for this facility. Infection control: LPA Stamps reviewed facility mitigation plan (approved on 03/06/21) to make sure licensee was following current infection control recommendations. Upon arrival the team was screened by the caregiver and asked all infection control questions. LPAs were asked to sign-in and sanitize/wash hands. LPA arrived at 11:15am and was greeted by caregiver Gabriella Topping. One (1) resident was observed in the living room watching TV. The rest of the residents were observed to be in their room sleeping, watching TV and/or resting. Administrator Fabiola Igid arrived at 11:25am. LPAs informed the Administrator of the purpose of the visit. A tour of the physical plant was conducted with Administrator at 11:30am. The facility has five (5) bedrooms and three (3) bathrooms currently occupying five (5) residents. One (1) bathroom is designated for staff use only and the facility has awake staff at night. The facility is Fire Cleared for two (2) ambulatory, four (4) non-ambulatory, and has a hospice waiver for one (1) resident. Resident Rooms LPAs observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. LPAs tested the exit doors auditory system and it was observed to be operational for each room. Bathrooms At 11:40AM LPAs observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 12:01pm and measured within regulation at 105.8 degrees F.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BEST ELDER CARE III	FACILITY NUMBER: 197606773
	VISIT DATE: 10/12/2021

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

Laundry
LPAs observed chemicals/hazardous items in a locked cabinet in the laundry room.

Food Inspection
LPAs conducted tour at the kitchen around 11:40am 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. LPAs observed all knives and sharp object being locked and inaccessible to residents in care.

Physical environment
LPAs toured the outside area of the facility at 11:56am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Living and dining
LPAs observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke detectors were tested and observed to be operational at 11:54am. There are two (2) fire extinguishers, one (1) is located in the kitchen and one (1) is located in the bedroom hallway. Fire extinguishers were observed to be full and last serviced on 06/02/21. Medication cabinet was located in a dining area and at 11:15am, and was observed to be locked and inaccessible to residents in care.
Garage
LPAs observed the garage to be attached to the facility and currently being used for an extra food storage and PPE supplies.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500. Annual fee is current.

An exit interview was conducted and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2