197606875-1-22-2024-31-AS-ERIS-CZR2P9-20240122163359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606875
Report Date: 01/22/2024
Date Signed: 01/22/2024 04:34:02 PM

Document Has Been Signed on 01/22/2024 04:34 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:	01/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Marita Samaniego		TIME COMPLETED:	04:45 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 01/22/2024 at 2:00 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual inspection. LPA was greeted by Staff #1 (S1). S1 asked LPA to sign in. S1 called the administrator Marita Samaniego. Marita met LPA shortly after. LPA explained the reason for the visit. The inspection tool was used to complete the visit. At 2:10 p.m. LPA began a physical plant tour of the facility and the following was observed: Kitchen: LPA observed required postings on a wall leading to the office. 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 and 7-day non perishable food supply; properly stored. The fire extinguisher was observed by the kitchen, fully charged with a receipt of purchase from 04/18/2023. Dining / Living Area: The dining and living area were clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area was not in use and secured with a glass screen. LPA observed the thermostat at a comfortable temperature of 72°F. Bedrooms: A fire extinguisher was observed in the hallway leading 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 on exit doors were functioning properly. LPA observed smoke detectors through out the facility that are interconnected. At 2:30 p.m. smoke and carbon detectors were tested and were observed to be functioning properly. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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
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: 01/22/2024

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 bathroom is accessible to all 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, paper towels and toilet paper. At approximately 3:30 p.m. water temperature in the main bathroom was measured at 111 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. Laundry detergent is kept locked in laundry room.

Resident/Staff Records: At approximately 3:00 p.m. five (5) out five (5) resident records and (2) staff records were reviewed to insure compliance.

Medications: Centrally stored medications are maintained locked in a kitchen cabinet. Medication requiring refrigeration is kept in a refrigerator in the garage inaccessible to residents. Medication Records were reviewed for proper documentation. Medication records were complete and updated.

No deficiencies were observed during todays visit. Exit interview conducted. Copy report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

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