197606875-12-13-2022-31-AS-ERIS-CM3RZE-20221213122750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606875
Report Date: 12/13/2022
Date Signed: 12/13/2022 12:28:17 PM

Document Has Been Signed on 12/13/2022 12:28 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A PLUS ELDERLY CARE		FACILITY NUMBER:	197606875
ADMINISTRATOR:	MARITA AMORSOLO		FACILITY TYPE:	740
ADDRESS:	43835 JOHNS COURT		TELEPHONE:	(661) 723-0212
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	12/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Marita Amorsolo		TIME COMPLETED:	12:30 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	On 12/13/2022 at 11:00 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA observed appropriate postings on outside of front door. LPA was greeted by Staff #1 (S1) who was wearing a mask and granted access. S1 asked LPA to sign in and record temperature. Temperature taken from device on the wall. LPA observed proper Covid-19 signs posted at entry way of the facility. S1 told LPA they would call administrator Marita Amorsolo. Marita met us shortly after. LPA explained the reason for the visit. LPA reviewed the Mitigation Plan approved 02/06/2021. The inspection tool was used to complete the visit. At 11:10 a.m. LPA began a physical plant tour of the facility and the following was observed: Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Knives are kept locked in a kitchen drawer inaccessible to residents. LPA observed a 2-day perishable food and 7-day non perishable food supply. Trash bin is located in a cabinet drawer in the island to prevent cross contamination. The fire extinguisher was observed by the kitchen and was fully charged. Dining / Living Area: The dining and living area were well lit, clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area is not in use. LPA observed the thermostat at a comfortable temperature of 76°F. Bedrooms: A fire extinguisher was observed in the hallway to the bedrooms and was fully charged. There are four (4) bedrooms designated for resident use. One (1) out of the four (4) rooms is shared. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens. Auditory alarms were placed on doors due to dementia residents in care.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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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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: A PLUS ELDERLY CARE	FACILITY NUMBER: 197606875
	VISIT DATE: 12/13/2022

NARRATIVE

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Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in the shared bedroom and the other main bathroom is accessible to all the residents. Both bathrooms were well lit, clean, had grab bars, had hand washing signs, nonskid mats and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels. At approximately 11:36 a.m. water temperature in the main bathroom was measured at 113.6 degrees Fahrenheit.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Gate on the side of the house was closed but unlocked. There is a covered patio space to provide shade and appropriate outdoor seating for residents. LPA observed one shed in the backyard being used for storage. There are no bodies of water.

Laundry Room: Laundry room is kept locked. LPA observed a washing machine and dryer that appeared operative. Cleaning and laundry detergent are kept locked in laundry room.

Medications/ Resident file: LPA observed, resident medications locked in a kitchen cabinet and resident files locked in the facility office inaccessible to residents.

LPA observed smoke alarms through out the facility that are interconnected. At 11:31 a.m. all smoke alarms were tested and functioned properly. LPA observed one carbon monoxide detector in hallway and it appeared to be functioning. Administrator states the facility has enough PPE for 30 days.

No deficiencies were observed during todays visit and the facility is currently following their infection control plan.

Exit interview conducted and a copy of this report issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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