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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608107
Report Date: 03/03/2022
Date Signed: 03/03/2022 03:32:34 PM

Document Has Been Signed on 03/03/2022 03:32 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:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Brenda DyerTIME COMPLETED:
03:30 PM
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LPA Spaeth conducted an unannounced visit to the facility and was greeted at the door by caregiver Keith Burns. LPA was then greeted by Administrator Brenda Dyer and LPA stated the purpose of the visit. LPA's temperature was taken, recorded, and LPA was asked to use hand sanitizer before entering and to sign in at the sign in station. LPA observed a sign in sheet, thermometer, additional PPE and hand sanitizer. LPA observed the Administrator and Caregiver were wearing a mask. Administrator confirmed there are four residents in the facility. Before beginning the tour, LPA confirmed there are three resident bedrooms, four bathrooms, laundry room, garage, and the Administrator's room.

LPA began the tour at 2:25 pm with the Administrator. LPA observed the dining room which contained a table and chairs. The kitchen pantry was well stocked with a ten day supply of canned vegetables. At 2:30 pm, LPA checked the cans and observed the expiration dates were within regulation compliance. LPA observed a locked cabinet underneath the sink which contained the knives and cleaning supplies. The medications were locked in a kitchen cabinet. The refrigerator was stocked with a five-day supply of fresh vegetables and fruits. All items in the refrigerator were covered. The freezer section contained an ample supply of frozen meats. LPA observed the menu was posted on the refrigerator. Also, LPA observed the fire extinguisher.

There were two residents in the family room watching television. The family room contained comfortable seating. LPA and Administrator walked into the backyard and LPA observed a resident sitting in the backyard enjoying the sunshine. The side gate was unlocked and the shed in the backyard was locked.

LPA then observed the downstairs bathroom which contained wash your hands sign, hand soap, paper towels and a trash can. The laundry room was locked and LPA was escorted into the room which contained the washer, dryer, and laundry detergent. The Administrator unlocked a closet which contained the resident files, additional PPE supplies, and hygiene items for the residents. LPA was escorted to the garage where LPA observed two additional freezers.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 03/03/2022
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LPA was then escorted to the second floor and observed the master bedroom/bathroom. Two residents occupy the room and LPA observed the beds were six feet apart. The master bathroom contained wash your hands sign, hand soap, paper towels, and a trash can. Two other residents have their own room. Each room contained beds, sheets, bedspread, night lamp, night stand, and a chair in each room. LPA observed another bathroom which also contained wash your hands sign, hand soap, paper towels, and a trash can. LPA observed Administrator unlocked the staff room then locked the room upon exiting.

LPA observed the COVID signs posted throughout the facility.

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

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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