197607859-5-24-2021-31-AS-MSPH-C3BVW2-20210524164713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607859
Report Date: 05/24/2021
Date Signed: 05/24/2021 04:48:29 PM

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:	DIANA'S MARIAN RES. CARE FACILITY 1 LLC		FACILITY NUMBER:	197607859
ADMINISTRATOR:	DIANA SORIANO		FACILITY TYPE:	740
ADDRESS:	44047 RODIN AVENUE		TELEPHONE:	(661) 726-7674
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	6	CENSUS: 4	DATE:	05/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Diana Soriano		TIME COMPLETED:	12:10 PM

NARRATIVE

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LPA Spaeth conducted an infection control visit with Administrator Diana Soriano. Upon arriving at the facility at 11:10 am, LPA observed the COVID 19 required signs posted on the front door. Upon entering the facility, LPA signed in and the Administrator took LPA’s temperature which was 97.7 and recorded on the sign in sheet. LPA Spaeth walked into the living and greeted a resident sitting on the sofa watching television. Administrator stated there are four ambulatory residents at the facility. Administrator also confirmed all residents and staff have received the COVID-19 vaccine.

After signing in, Administrator confirmed first door on the left is the staff bedroom. Administrator stated Administrator and husband which is a caregiver live at the facility since COVID began. Administrator stated Administrator’s family members pick up all the supplies needed so that Administrator and husband can stay safe. Administrator confirmed Administrator has not left facility but rely on others to drop off supplies at the front door of the facility.

Upon walking through the living room, LPA observed a couch and several comfortable chairs available for residents to sit. LPA also noted the chairs were located within the room so that social distancing can be observed. LPA observed the dining room and was told by Administrator two residents sit at the dining room table during meals and the other two residents sit at other locations for social distancing purposes.

LPA Spaeth toured the kitchen and observed an adequate supply of food in the refrigerator, freezer, and pantry section of the kitchen. LPA saw there was hand soap, paper towels, and wash your hands sign in the kitchen. Administrator also pointed to the kitchen table in the kitchen where there was a variety of fruits available for the residents. The Administrator

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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: DIANA'S MARIAN RES. CARE FACILITY 1 LLC	FACILITY NUMBER: 197607859
	VISIT DATE: 05/24/2021

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opened the locked cabinet which contained the knives and unlocked a cabinet which contained residents’ medications. The cabinet underneath the sink which was locked and contained cleaning supplies.

Administrator escorted LPA down the hall and LPA observed three residents’ rooms in which residents did not share a room. A husband and wife resident share a room and LPA observed the twin beds were six feet apart. Upon arriving at the bathroom, Administrator stated resident was in the bathroom but confirmed with LPA the bathroom contained wash your hands sign, hand soap, paper towels, and a trash can.

Administrator then unlocked the door that leads to the garage. LPA observed boxes of PPE, the laundry area, and a freezer. Administrator showed LPA several PPE boxes which contained gloves, N-95 masks, gowns and hand sanitizer. Administrator confirmed has a six-month supply of PPE items. Upon exiting the garage, LPA observed a cabinet which contained a supply of PPE available for use.

LPA Spaeth confirmed the facility is cleaned and sanitized once per day and LPA observed the facility was thoroughly clean when conducting the tour. Administrator confirmed there are an on-call staff members but Administrator has not had to call the staff member because Administrator and caregiver (husband) live at the facility. Administrator stated talks to on-call staff members on a weekly basis. Administrator explained since there are only four residents, will only use on-call staff members if there is an emergency. LPA Spaeth asked to review the daily recording of residents’ temperatures. Administrator showed log-in folder but LPA Spaeth observed some of the residents’ temperatures were not recorded. Administrator stated will go back and update the log.

The tour concluded at 12:10 pm. Exit interviewed was conducted and LPA Spaeth stated will send report to Administrator via email. LPA Spaeth instructed administrator to sign and send to LPA via email.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC809 (FAS) - (06/04)

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