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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606868
Report Date: 03/07/2022
Date Signed: 03/07/2022 02:59:25 PM


Document Has Been Signed on 03/07/2022 02:59 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:GUMA RESIDENTIAL CARE FOR THE ELDERLYFACILITY NUMBER:
197606868
ADMINISTRATOR:VIRGINIA GUMAYAGAYFACILITY TYPE:
740
ADDRESS:544 WEST AVENUE J-15TELEPHONE:
(661) 579-6039
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 2DATE:
03/07/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:VIRGINIA GUMAYAGAYTIME COMPLETED:
03:00 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and was met by Administrator Virginia Gumayagay at the front door. LPA's temperature was recorded and LPA observed Administrator and Caregiver were wearing a mask. LPA stated the purpose of the visit was to clear the two deficiencies.

At 2:25 pm, LPA observed the cabinet underneath the kitchen sink now has a lock and LPA observed Administrator unlock the cabinet. Also, LPA observed a kitchen drawer which was locked. LPA observed the knives were safely locked in the kitchen drawer.

LPA was then escorted to the bathroom and observed a lock had been installed to the cabinet sink. At 2:35 LPA observed Administrator unlocked the bathroom cabinet and LPA observed the cleaning supplies were also safely locked in the cabinet.

LPA then stated to Administrator the two deficiencies were cleared. There are no other deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the report was given to administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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