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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607357
Report Date: 12/13/2023
Date Signed: 12/13/2023 04:06:06 PM

Document Has Been Signed on 12/13/2023 04:06 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:DAVENPORT HOME, THEFACILITY NUMBER:
197607357
ADMINISTRATOR:GAMZE DAVENPORTFACILITY TYPE:
735
ADDRESS:5722 PADDINGTON DRIVETELEPHONE:
(661) 533-9790
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 3DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Gamze DavenportTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 12/13/2023. LPA was greeted by the Administrator. The facility is licensed for six ambulatory clients and there are three clients living in the facility.

LPA Spaeth and the Administrator began the tour at 1:20 pm until 1:48 pm. LPA observed the following:

Common areas – The living room and family room contained comfortable seating. The upstairs loft also contained comfortable seating with a television.

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. Fire extinguishers were located near the kitchen area and were operable. The pantry room was locked and contained canned goods on one side of the room and cleaning solutions along with the knives were safely locked in the room.



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

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

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 on the second floor.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: DAVENPORT HOME, THE
FACILITY NUMBER: 197607357
VISIT DATE: 12/13/2023
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Bathrooms – LPA observed the bathroom which contained contained hand soap, paper towels, and covered trash cans. The water temperature was tested in at 1:45 pm and was 114 degrees F.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 1:48 pm 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.

LPA reviewed client records at 1:45 pm until 2:15 pm. LPA also reviewed staff records at 2:30 pm. LPA checked resident medications at 2:50 until 3:00 pm.

LPA reviewed P&I records 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 signed report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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