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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608023
Report Date: 09/22/2021
Date Signed: 09/22/2021 04:28:56 PM

Document Has Been Signed on 09/22/2021 04:28 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:SUNGATE CARE FACILITYFACILITY NUMBER:
197608023
ADMINISTRATOR:TASHA KANALEYFACILITY TYPE:
735
ADDRESS:3441 SUNGATE DR.TELEPHONE:
(661) 526-7848
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Dolly Barraza TIME COMPLETED:
03:45 PM
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LPA Spaeth conducted an unannounced annual visit. LPA arrived at 2:45 pm and observed the COVID signs at the front door. LPA was greeted by caregiver Michelle Fernandez and was escorted to the living room. LPA Spaeth stated the purpose of the visit is to complete an annual inspection. LPA was asked the COVID questions and LPA's temperature was taken at 2:56 pm. LPA observed the sign in station which contained
hand sanitizer, sign in sheet, thermometer and masks.

At 3:00 pm, LPA was escorted by caregiver, Dolly Barraza for a tour and observed the family room, dining room and kitchen are all combined together. LPA entered the kitchen and observed wash your hands sign, hand soap, paper towels and a trash can. LPA observed the pantry was well organized and contained an adequate supply of canned goods and cereal. The frozen section of the refrigerator contained frozen meats and vegetables. The refrigerator was well stocked with fresh fruits, fresh vegetables, juice, and other fresh food items. All food was covered and labeled. LPA observed the facility menu was posted on the refrigerator.

LPA observed the family room and living room contained comfortable seating for the residents. The family contained a television. LPA observed the common areas of the facility were clean and all furniture was in good repair.

LPA observed a locked, hall closet which contained the knives locked in a plastic container and the resident medications. The medications were individually stored for each resident in a plastic bin marked with the resident's name. LPA observed a 90 day supply of PPE which includes N95 masks, surgical masks, hand sanitizer, gloves, and other items. Also, linens were stored in the hallway storage area for the residents.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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: SUNGATE CARE FACILITY
FACILITY NUMBER: 197608023
VISIT DATE: 09/22/2021
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There are four bedrooms and LPA observed the bedrooms contained lamp, night stand, and chest of drawers for residents to store personal clothing. Each contained the required linens -- comfortable bed, bed sheets, pillow and mattress protector on each mattress. LPA observed all resident rooms were neat and clean.

There are two bathrooms which each contained the COVID required items including wash your hands sign, hand soap, paper towels, and trash cans. LPA observed all bathrooms were clean.

LPA Spaeth was then escorted by the caregiver to the laundry room. The caregiver unlocked the door and LPA observed all cleaning supplies and laundry detergent were safely stored in cabinets within the laundry room. The caregiver then unlocked the door that leads to the garage. LPA Spaeth walked into the garage and observed a freezer which contained additional food. LPA was then escorted through the sliding glass door in the family room to the backyard. LPA Spaeth observed comfortable seating for residents. The gate which leads from the backyard to the front yard was unlocked.

LPA Spaeth confirmed that all residents temperatures are recorded each day. At 3:42 pm, LPA observed the resident temperature sheets which was located in a binder at the front door. Caregivers confirmed the facility is cleaned and sanitized at least two times per day.

There are no deficiencies to report at this time. Exit interview conducted and a copy of the report given to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC809 (FAS) - (06/04)
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