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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607398
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:24:36 AM

Document Has Been Signed on 03/16/2022 11:24 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:VIP ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197607398
ADMINISTRATOR:TEKOA HUEYFACILITY TYPE:
735
ADDRESS:37636 RUBY LANETELEPHONE:
(661) 533-3986
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 4DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jermarcus Dumas, StaffTIME COMPLETED:
11:40 AM
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At 10:15am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by Jermarcus Dumas (JD), who granted access to the facility. Administrator was contacted over the phone and LPA explained the reason for the visit.

Physical tour was conducted with the JD and LPA observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 03/28/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions and offered a hand sanitizer. Proper signage was observed inside along the hallway and in the restrooms. JD stated they have sufficient PPE supplies for clients and staff. LPA observed all trash cans throughout the facility have fitted lids.

Kitchen: At approximately, 10:20am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. LPA observed all knives and sharps locked in a drawer and inaccessible to clients in care. The fire extinguisher was purchased on 03/16/2022



Medications: At approximately, 10:25am LPA observed medications are centrally stored and locked in the kitchen cabinet.

Common Areas: The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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: VIP ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197607398
VISIT DATE: 03/16/2022
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Bedrooms: There are three (3) bedrooms designated for clients use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens.

Bathrooms: At 10:35am LPA observed all bathrooms are clean and in good repair. The hot water temperature measured at 110.6°F. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom.



Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:40am they were tested and observed to be operational.

The garage: Laundry area is located in an attached garage and kept locked and inaccessible to clients. Extra PPE supplies and food storage was also observed.



Outside areas: At approximately, 10:45am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

Administrative: LPA collected Certificate of Liability Insurance, and LIC.500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to the Administrator..

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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