197607859-11-22-2023-31-AS-LCAS-CXTRUN-20231122122013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607859
Report Date: 11/22/2023
Date Signed: 11/22/2023 12:20:24 PM

Document Has Been Signed on 11/22/2023 12:20 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.RO, 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: 5	DATE:	11/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Diana Soriano		TIME COMPLETED:	12:30 PM

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Licensing Program Analysts (LPAs) Lorena Casillas and Melissa Spaeth arrived at the facility at 10:00 am. LPAs were greeted by Administrator Diana Soriano.

A tour of the physical plant was conducted with the Administrator at 10:30 am. The facility has four (4) bedrooms and two (2) bathrooms. It is currently occupied by five (5) clients. One (1) bedroom and one (1) bathroom are designated for staff use only.

Infection control: LPAs reviewed facility infection control plan (approved on 03/20/2021) to make sure licensee was following current infection control recommendations.

Kitchen: LPAs conducted a tour of the kitchen around 10:35 am and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Medication and knives stored in locked cabinets. First aid kit furnished and fully equipped.

Living/dining/family: LPAs observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 69°F. LPAs observed staff and client files locked in the filing cabinet. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:50 am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 04/04/2023.

Bedrooms: LPAs observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client. LPAs observed sufficient linens and towels in the hallway closet.

Continued....

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DIANA'S MARIAN RES. CARE FACILITY 1 LLC	FACILITY NUMBER: 197607859
	VISIT DATE: 11/22/2023

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Bathrooms: LPAs observed bathroom to have the appropriated wash your hands signs posted. The bathroom was clean, with soap and paper towels for clients. Hot water was tested at 10:54 am in the client bathroom 119.2 degrees Fahrenheit.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The gate was unlocked and easily accessible. There is a covered patio and furniture for clients. Garage entrance was locked and secure. Garage contains PPE equipment, laundry area and a freezer that has plenty of frozen food that was wrapped and stored appropriately. There is a storage area with additional canned items along with emergency food and water. Chemicals and household supplies locked and stored in locked cabinet in the garage.

Administrative: LPAs collected the LIC.500 and resident roster. Annual fees are current.

Resident Files: LPAs conducted a file review of resident records to ensure compliance of licensing forms at 10:50 am.

Staff Files: LPAs conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms at 11:15 am.

Medications: At 11:30 am LPAs and staff reviewed medication and medication records for proper documentation.

No deficiencies were observed, an exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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