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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608023
Report Date: 11/06/2023
Date Signed: 11/06/2023 01:53:50 PM

Document Has Been Signed on 11/06/2023 01:53 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: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:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Dolly BarrazaTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by a caregiver. The facility is licensed as an adult residential facility to serve three ambulatory clients and one non-ambulatory client.

LPA and the caregiver began the tour of the facility at 9:10 am until 9:55 am. LPA observed the following:

Living Room– LPA Spaeth observed the living room contained comfortable seating.

Kitchen/Dining room - The dining room and kitchen are combined. LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The fire extinguisher is located in the kitchen.

Hallway Closet - The closet was locked and contained the knives, client medications and the first aid kit.

Laundry Room - The laundry room was locked and contained laundry soap, washing machine, dryer, client hygiene items, additional PPE, and cleaning supplies.

Bathrooms – LPA Spaeth observed the bathrooms contained hand soap, paper towels, and a trash can. LPA tested the water temperature at 10:29 am and was 106.0 F.

Bedrooms – LPA Spaeth observed there are four client bedrooms in the facility. The bedrooms contained bed, linens, night stand, chair, chest of drawers, and a night lamp.

Office– LPA observed the staff office was locked

Cont'd 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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: SUNGATE CARE FACILITY
FACILITY NUMBER: 197608023
VISIT DATE: 11/06/2023
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Garage - The garage was locked and a freezer was observed and contained additional meats.

Backyard – LPA Spaeth observed comfortable seating in a shaded area. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detector were tested at 9:55 am and are operational.

LPA reviewed staff files at 10:00 am until 10:20 am. LPA reviewed client files at 10:20 am until 10:55 am. LPA reviewed P&I at 11:00 am until 11:10 am. LPA reviewed client medications at 11:10 am until 11:20 am.

There are no deficiencies at this time.



Exit interview conducted, and a copy of the signed report was given to caregiver.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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