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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608107
Report Date: 11/24/2021
Date Signed: 11/24/2021 12:45:41 PM

Document Has Been Signed on 11/24/2021 12:45 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:DYER ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197608107
ADMINISTRATOR:BRENDA DYERFACILITY TYPE:
735
ADDRESS:40643 CHAMPION WAYTELEPHONE:
(661) 480-0785
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Randy Dyer Oscar AlbaridaTIME COMPLETED:
12:45 PM
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LPA Spaeth conducted an unannounced annual visit and arrived at 10:20 am. LPA was greeted by Licensee, Randy Dyer and LPA confirmed the purpose of today's visit. Upon approaching the front door, LPA observed the COVID signs posted on the door. Upon entering the facility, LPA observed the sign in station. LPA's temperature was recorded, sign in sheet available, hand sanitizer and masks were also located at the front door. LPA was also greeted by the Administrator, Oscar Albarida. Administrator and licensee confirmed there are four ambulatory residents.

When entering the living room, LPA observed three residents watching television in reclining chairs which were social distanced in the room. LPA observed the dining room where seating was available and the chairs were six feet apart. The Licensee then showed LPA a six month supply of PPE which included N95 masks, gloves, surgical masks, gowns, and hand sanitizer.

Upon entering the kitchen, LPA observed the wash your hands sign, paper towels, trash can and hand soap at the kitchen sink. At 11:00 am, Administrator unlocked the cabinet under the kitchen sink and LPA observed the cleaning supplies. LPA observed the refrigerator contained fresh vegetables and fruits, dairy products and other perishable foods items. The freezer contained a large supply of frozen meats. LPA observed the pantry contained canned vegetables, pasta, rice, and canned fruits. The knives were properly locked in a kitchen cabinet.

All parties then entered the family room and LPA observed comfortable seating. The medications were locked in a cabinet in the family room. Upon exiting the facility to the backyard, LPA observed a swimming pool which was locked. The backyard also contained comfortable seating in a shaded area. LPA observed a resident sitting in the sunshine. The gate leading from the backyard to the front yard was not locked. LPA also observed a separate small building which was the administrator's office. The office was locked.



SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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: DYER ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197608107
VISIT DATE: 11/24/2021
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Upon entering back into the facility to the family room, LPA observed the locked laundry room which contained the laundry soap and additional cleaning supplies. The Administrator was washing the residents' clothing during the visit. LPA observed a locked door which was unlocked by the Licensee. Upon entering the garage, LPA observed an additional refrigerator which contained additional frozen vegetables and frozen meats. LPA also observed a bathroom which contained wash your hands sign, hand soap, paper towels, and a trash can.

The Licensee then escorted LPA to the second floor of the facility. LPA observed three resident bedrooms which contained a bed, linens, proper lighting and storage area for the resident's clothing. LPA observed two staff rooms which were locked on the second floor of the facility. There are two bathrooms on the second floor. All the bathrooms contained slip resistant mats, wash your hands sign, hand soap, paper towels, and a trash can. The resident hygiene items were locked in a cabinet on the second floor. LPA observed an adequate supply of hygiene items and additional cleaning supplies locked in the second floor cabinet.

There are no deficiencies to report at this time. Exit interview was conducted, appeal rights discussed, and a copy of the signed report was
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
LIC809 (FAS) - (06/04)
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