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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607345
Report Date: 11/08/2024
Date Signed: 11/08/2024 12:27:31 PM

Document Has Been Signed on 11/08/2024 12:27 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:IVAN BANNER BOARDING CAREFACILITY NUMBER:
197607345
ADMINISTRATOR/
DIRECTOR:		CYNTHIA TAYLORFACILITY TYPE:
740
ADDRESS:39409 DAYLILY PLACETELEPHONE:
(661) 267-0779
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Donald FeaginTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 11/08/2024. LPA was greeted by the caregiver. The facility is licensed for six ambulatory residents and there are five residents living in the facility.

LPA Spaeth viewed the residents' records at 9:30 am until 10:15 am. LPA Spaeth reviewed resident's medication at 10:15 until 10:30 am. LPA reviewed staff files at 10:30 am until 10:40 am.

LPA Spaeth and the caregiver began the tour at 9:40 am until 10:13 am. LPA observed the following:

Common areas – The living room and family room contained comfortable seating. The dining room contained a dining room table and chairs.

Kitchen – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food. There were no cleaning solutions stored underneath the kitchen sink. A fire extinguisher was located in the kitchen area.



Pantry Room - The pantry room was locked and contained canned goods on one side of the room and cleaning solutions on the other side of the room. The washer and dryer were located in the pantry room.

Garage – The garage was locked. There were no hazardous items in the garage.

Continued on 809-C
Troy AgardTELEPHONE: (818) -596-4334
Melissa SpaethTELEPHONE: (818) 421-2278
DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVAN BANNER BOARDING CARE
FACILITY NUMBER: 197607345
VISIT DATE: 11/08/2024
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Resident Rooms - LPA observed the resident rooms contained bed, linens, night stand, lamp, closet and chest of drawers.

Medications - The medications were locked in a two drawer cabinet located in the dining room.

Resident files - The residents' files were locked in a two drawer cabinet located in the dining room.

Staff Room - The staff room was locked.

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



Water Temperature – LPA tested the water at 11:50 am and was 116.0 degrees F.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 10:45 am and were operable.



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

There are no deficiencies to report at this time.

Exit interview conducted and a copy of the signed report was given.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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