197606875-1-15-2025-31-AS-ERIS-DCY2QR-20250115163622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606875
Report Date: 01/15/2025
Date Signed: 01/15/2025 04:36:28 PM

Document Has Been Signed on 01/15/2025 04:36 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/ DIRECTOR:	MARITA AMORSOLO		FACILITY TYPE:	740
ADDRESS:	43835 JOHNS COURT		TELEPHONE:	(661) 723-0212
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:07 PM
MET WITH:	Lily Anne Gagarin		TIME VISIT/ INSPECTION COMPLETED:	04:50 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 01/15/2025 at 2:07 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct an unannounced Required Annual inspection. LPA was greeted by Staff #1 (S1). LPA signed in and checked temperature by entry. S1 called the administrator. Lily Anne Gagarin the administrator designee met LPA shortly after. LPA explained the reason for the visit. This is a Residential Care Facility for the Elderly (RCFE) with an approved fire clearance for 6 bedridden residents with a hospice waiver for 4. The inspection tool was used to complete the visit. At 2:12 p.m. LPA began a physical plant tour of the facility inside and out 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. LPA observed an adequate amount of tableware for the capacity of the facility. 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 and labeled. The fire extinguisher was observed by the kitchen, fully charged with a receipt of purchase from 03/04/2024. 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 71°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. LPA observed a built in closet with extra linens. Auditory alarms on exit doors were functioning properly. (Continued on LIC809-C)

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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: 01/15/2025

NARRATIVE

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(Continued from LIC809) 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, nonskid mats and trash bins with lids. LPA observed a sufficient supply of hand soup, paper towels and toilet paper. At approximately 2:26 p.m. water temperature in the main bathroom was measured at 112.1 degrees Fahrenheit, within regulation.

LPA observed dual smoke and carbon monoxide detectors through out the facility that are interconnected. At 2:38 p.m. smoke and carbon detectors were tested by staff and were observed to be functioning properly.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. 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/Garage: Washer and dryer are located in the garage and it is kept locked. LPA observed a washing machine and dryer that appeared operative. Laundry detergent is kept locked in the garage. LPA observed a second facility refrigerator. Medication requiring refrigeration is kept in a refrigerator in the garage inaccessible to residents.

Resident/Staff/Facility Records: At approximately 3:06 p.m. LPA reviewed The Emergency and Disaster Plan (LIC610E), Fire and Earthquake drills, Certification of Liability, Personnel Report (LIC500) and Infection Control Plan. LPA provided PIN to designee to pay licensing fee online. At 3:20 p.m. LPA reviewed five (5) out five (5) resident records and (2) staff records were reviewed to ensure compliance.

Medications: Centrally stored medications are maintained locked in a kitchen cabinet. Medication Records were reviewed for proper documentation. Medication records were complete and up to dated. LPA observed a fully stocked first aid kit.

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: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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