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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607183
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:51:38 PM

Document Has Been Signed on 12/21/2023 03:51 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: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:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Belinda HicksTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 12/21/2023. LPA was greeted by the caregiver and the Administrator Belinda Hicks arrived at 1:00 pm. The facility is licensed for four ambulatory clients and there are four clients living in the facility.

LPA Spaeth and the Administrator began the tour at 1:10 pm until 1:30 pm. LPA observed the following:

Common areas – The living room and family room contained comfortable seating.

Kitchen – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food. The cleaning solutions were locked underneath the kitchen sink. A fire extinguisher is located near the kitchen area and was operable. The medications, first aid kit and knives were locked in a kitchen cabinet.



Laundry Area - The laundry room was locked and contained the washer and dryer.

Garage – The garage was locked and contained emergency food and water and additional refrigerator.

Resident Rooms - LPA observed the resident rooms contained bed, linens, night stand, lamp, closet and chest of drawers. All rooms were neat and clean.

Bathrooms – LPA observed the bathroom which contained hand soap, paper towels, and covered trash cans.

Water Temperature - The water temperature was tested in at 1:20 pm and was 117.0 degrees F.

Backyard - LPA observed the backyard which has a shaded area. The gate leading from the backyard to the front yard was not locked.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AVENUE "H" GUEST HOME, INC.
FACILITY NUMBER: 197607183
VISIT DATE: 12/21/2023
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Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 2:40 pm and were operable.

LPA reviewed client records and staff records at 1:35 pm until 3:20 pm.

LPA reviewed P&I records at 2:20 pm and 2:45 pm. LPA checked medications at 2:45 pm until 2:50 pm.

There are no deficiencies to report at this time. Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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