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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607183
Report Date: 09/09/2022
Date Signed: 09/09/2022 09:26:44 AM

Document Has Been Signed on 09/09/2022 09:26 AM - 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:AVENUE "H" GUEST HOME, INC.FACILITY NUMBER:
197607183
ADMINISTRATOR:JOEL FLETCHERFACILITY TYPE:
735
ADDRESS:3640 AVENUE H-13TELEPHONE:
(661) 916-7507
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Belinda Hicks,Co- AdministratorTIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA) Shira Stamps met with administrator Belinda Hicks for an unannounced one (1) year Required visit for this facility. LPA arrived at 7:45 am and was greeted by the caregiver. All clients were observed in the living room. The Administrator arrived at 8:00 am. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA Stamps reviewed facility mitigation plan (approved on 03/13/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was signed-in and sanitizer was available.

A tour of the physical plant was conducted with Administrator at 8:08 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for four (4) ambulatory.

Food Inspection
LPA conducted tour at the kitchen around 8:10 am observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object, medications, and first aid kit being locked and inaccessible to clients in care.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 8:25 am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 04/11/22. CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AVENUE "H" GUEST HOME, INC.
FACILITY NUMBER: 197607183
VISIT DATE: 09/09/2022
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Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client.

Bathrooms
At 8:20 am LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested, and measured within regulation at 120.0 degrees F.

Laundry
LPA observed no chemicals/hazardous items in the laundry room.

Physical environment
LPA toured the outside area of the facility at 8:21 am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Garage
LPA observed the garage to be attached to the facility and currently being used for an extra food storage and PPE supplies.

Administrative: LPA collected the LIC.500 and client roster. Annual fee is current. LPA reminded the Administrator to maintain client and staff files.

An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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