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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606814
Report Date: 12/19/2023
Date Signed: 12/20/2023 08:01:59 AM

Document Has Been Signed on 12/20/2023 08:01 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:PROJECT INDEPENDENCEFACILITY NUMBER:
197606814
ADMINISTRATOR:KATHLEEN MILLERFACILITY TYPE:
775
ADDRESS:43439 COPELAND CIRCLETELEPHONE:
(661) 948-8402
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 102CENSUS: 98DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Lorraine Mckesson- DTAC ManagerTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced required annual visit. LPA met with Lorraine Mckesson DTAC Manager. LPA requested copies of LIC 500 and Clients Attendance Sheet. A tour of the physical plant was conducted to observe and ensure there were no health and safety hazards existed. Common Areas: The day program consisted of several activity rooms which were for Home economics, Computer lab, Arts and Crafts, and Hygiene room. LPA observed cleaning cart left unattended with cleaning solutions accessible to clients in the hallway. Rest-rooms: There were 2 rest-rooms designated for clients, one for males, one for females. The restrooms were properly supplied, clean and had functional fixtures. The hot water temperature measured at 103.4F. Kitchen: The facility has two (2) kitchens. One (1) designated for client's use and One (1) designated for staff. LPA observed in the Client's kitchen sharp objects unlocked in the pantry. LPA also observed that the kitchen used by staff was unlocked and there was a powder cleanser with bleach at the kitchen sink. Under the sink cabinet was also unlock and other cleaning supplies were accessible to clients. The kitchen was clean with functional equipment. LPA observed in the kitchen first aid kit and fire extinguisher with date of charge 11/14/23. The last fire/emergency drill was conducted at the facility on 11/29/23 .Surrounding Grounds: The facility had a patio area with covered seating for clients use. A review of Staff and Client Files was conducted. All files reviewed were complete and current.
Exit Interview conducted. Citations issued, copy of appeal rights and report delivered.


SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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 3
Document Has Been Signed on 12/20/2023 08:01 AM - It Cannot Be Edited


Created By: Mariana Agban On 12/19/2023 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PROJECT INDEPENDENCE
FACILITY NUMBER: 197606814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)


This requirement is not met as evidenced by: Buildings and Grounds: (a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed the cleaning cart unattended, cleaning solutions and sharp objects unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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Administrator locked cleaning supplies and sharp objects. Administrator provide a proof of purchase of lock box for the cleaning cart.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/23/2025 04:38 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/16/2025 11:15 AM


Created By: Mariana Agban On 12/19/2023 at 03:27 PM
Link to Parent Document Below:
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: PROJECT INDEPENDENCE
FACILITY NUMBER: 197606814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
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