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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607610
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:20:20 PM

Document Has Been Signed on 11/30/2023 03:20 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: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: 72DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kimberley HagerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Program Director. LPA stated the purpose of the visit was to conduct an annual inspection.

A tour of the physical plant was conducted at 11:00 am until 11:20 am and the following observed:

KITCHEN: The kitchen is used for cooking classes. Meals are not provided by the program. The kitchen appliances appeared to be in good working condition. There were no visible hazards.

COMMON AREAS: These included separate rooms for computer skills, games, arts & crafts, fitness, media, and quiet room. All common areas appeared to be adequately equipped for their intended use and there were no visible hazards. Equipment was observed to be maintained and in good condition. Three (3) fire extinguishers were observed along the hallways and appeared to be fully charged. Fire extinguishers were last checked on 10/27/2023. The facility is equipped with fire sprinklers. Smoke alarms and carbon monoxide were observed to be installed throughout the facility. LPA observed the smoke alarms are hard wired.

STAFF AREAS: There were multiple offices for various staff. Storage areas and other areas designated for staff only were observed to be locked, secured and inaccessible to clients.

BATHROOMS: There were four (4) bathrooms designated for clients use. All bathrooms were properly supplied and had functional fixtures.

WATER TEMPERATURE: LPA Spaeth checked the water temperature at 10:14 am which was 109.2F.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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: SVS - PALMDALE ADULT DAY PROGRAM
FACILITY NUMBER: 197607610
VISIT DATE: 11/30/2023
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CLIENT FILES: LPA reviewed the client files at 11:20 until 12:15 pm. All files reviewed were complete and current.

STAFF FILES: All staff files present were reviewed at 1:00 until 1:40 pm. All staff files reviewed appeared to be complete and current.

There are no deficiencies to report. The exit interview was conducted, and a copy of the signed report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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