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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607345
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:44:22 PM

Document Has Been Signed on 12/07/2022 02:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:IVAN BANNER BOARDING CAREFACILITY NUMBER:
197607345
ADMINISTRATOR:CYNTHIA TAYLORFACILITY TYPE:
740
ADDRESS:39409 DAYLILY PLACETELEPHONE:
(661) 267-0779
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 3DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Donald FagenTIME COMPLETED:
11:30 AM
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LPA Spaeth conducted an unannounced annual visit and arrived at 10:30 am. LPA observed the COVID signs on the front door and was greeted by the caregiver who was wearing a mask.. Upon entering the facility stated the purpose of the visit.. The caregiver confirmed there are three residents. Two residents were participating in an adult program and one resident was asleep in room. LPA and Caregiver began the tour at 10:35 am until 11:00 am.

LPA observed the living room and dining room which contained comfortable seating. LPA was directed to the family room and kitchen combination. LPA observed comfortable seating in the family room. A kitchen table was also located in the area alongside the kitchen.

At 10:45 am, LPA observed the knives were locked in a kitchen cabinet. LPA Spaeth observed hand soap, paper towels, and trash can. LPA also observed a two day supply of perishable items and a seven day supply of non perishable food items. The freezer contained frozen meats. LPA was escorted to the locked laundry room and observed the washer and dryer along with laundry detergent. LPA Spaeth observed the locked garage which contained PPE supplies which contained N-95 masks and other PPE supplies.

The Administrator then escorted LPA to the second floor and LPA observed a resident room for two residents. The beds were six feet apart and were clean. The residents' room contained lamp, night stand and chest of drawers. LPA observed another resident room where a resident was sleeping. LPA observed the bathrooms which contained wash your hands sign, hand soap, paper towels, and a trash can. At 11:00 am, LPA observed the medications were locked in a two drawer cabinet.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report was provided to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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