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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606868
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:56:19 PM


Document Has Been Signed on 03/13/2024 03:56 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: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: 0DATE:
03/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:VIRGINIA GUMAYAGAYTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and arrived at 10:30 am. LPA was greeted by the Licensee/Administrator, Virginia Gumayagay. LPA Spaeth stated the purpose of the visit was to conduct an annual inspection. The Administrator stated there are no residents living in the facility.

LPA Spaeth and the Administrator began the tour at 10:45 am until 11:00 am. LPA observed the three residents' rooms (Bedroom #1, #2, and #3) were empty. The Administrator confirmed they are still living in the facility and still resides in the master bedroom. LPA viewed the master bedroom and did not observe any residents in the room. The extra room located on the south side of the facility was empty.

The Administrator stated they have considered selling the business to a prospective buyer but the Administrator has not received an offer from the prospect.

There are no deficiencies to report at this time. The exit interview was conducted and a copy of the report was given.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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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