197606773-2-7-2024-31-AS-MSPH-D294RV-20240207182032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606773
Report Date: 02/07/2024
Date Signed: 02/07/2024 06:20:36 PM

Document Has Been Signed on 02/07/2024 06:20 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:	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:	DATE:	02/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	FABIOLA IGID		TIME COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are three residents living in the facility. The facility is licensed for two (2) ambulatory and four (4) non-ambulatory residents and a hospice waiver for one resident.

LPA Spaeth and the Administrator toured the location at 11:00 am until 11:45 am

Common Areas – The living room and dining room are combined. The living room was furnished with comfortable seating. The dining room contained dining room table and chairs. The family room contained a television and comfortable seating.

Medications: LPA observed the resident medications were safely locked in a cabinet in the living room.

Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The knives and cleaning solutions were locked underneath the kitchen sink. The fire extinguisher was located in the kitchen and was operable.

Hallway- The linens were located in a hallway cabinet.

Laundry Area – The laundry area contained the washer and dryer. The laundry detergent was locked in a cabinet above the washer.

Garage - LPA observed the garage was locked. The emergency food and water were stored in the garage. An additional refrigerator contained additional frozen food and dairy products.

Continued on 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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: BEST ELDER CARE III	FACILITY NUMBER: 197606773
	VISIT DATE: 02/07/2024

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Bathrooms: There are two (2) bathrooms designated for resident’s use. All bathrooms were well lit, clean, had grab bars, nonskid mats and trash bins with lids. At 11:45 a.m. the water temperature measure was 109.0 degrees F.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. There is a covered patio to provide shade and appropriate outdoor seating for residents.

Smoke/Carbon Monoxide Detectors: The smoke alarms were tested at 11:00 am and were operable. The carbon monoxide detector was tested at 11:10 am and was operable.

LPA reviewed resident files at 12:00 pm until 12:40 pm. LPA reviewed staff records at 12:45 pm until 1:00 pm. LPA Spaeth reviewed resident medications at 1:00 pm until 1:20 pm.

There are no deficiencies to report at this time.

Exit interview conducted and a copy of this report issued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC809 (FAS) - (06/04)

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