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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607610
Report Date: 12/05/2022
Date Signed: 12/07/2022 02:45:11 PM

Document Has Been Signed on 12/07/2022 02:45 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:SVS - PALMDALE ADULT DAY PROGRAMFACILITY NUMBER:
197607610
ADMINISTRATOR:LETTY CAMPBELLFACILITY TYPE:
775
ADDRESS:38420 5TH STREET WEST STE A-DTELEPHONE:
(661) 274-4840
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 60CENSUS: 0DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kimberley HagerTIME COMPLETED:
02:30 PM
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LPA Spaeth conducted an unannounced visit and was greeted by the receptionist upon arrival. LPA observed the receptionist was wearing a mask. LPA observed the required COVID signs on the front door. LPA's temperature was recorded and LPA signed in on the sign in sheet at the front entrance. LPA was greeted by the Program Director who stated there are no clients reporting to the program location but the clients are out in the community each day with staff members. When picking up consumers, staff members take client's temperatures and ask the COVID questions. PPE is also supplied in each van.

LPA and the Program Director began the tour at 1:35 pm until 1:55 pm. LPA observed twelve offices throughout the location for staff members to complete daily paperwork. LPA observed two offices were large and two staff members were social distanced and working at tables within those rooms. LPA observed a trash can, hand sanitizer, and disinfectant wipes in each office.

The kitchen, break room and conference room all contained disinfectant wipes, hand sanitizer and trash cans. There are four restrooms in the building and all contained wash your hands sign, hand soap, paper towels, and trash cans.

The Program Director escorted LPA to a locked cabinet which contained a 90 day supply of masks, hand sanitizer, paper towels, and disinfectant wipes. Also, an office file cabinet contained additional PPE for the staff when leaving the facility to work with clients within the community. The Program Director confirmed frequently touched surfaces are sanitized once a day.

There are no deficiencies to report at this time. The exit interview was conducted by LPA Spaeth. Due to technical difficulties, LPA emailed the signed report to the Program Director.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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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