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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608107
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:24:44 PM

Document Has Been Signed on 03/15/2024 03:24 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: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:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Brenda DyerTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are four residents. LPA observed two clients waiting for transportation to their adult day program. LPA observed the two were picked up at 9:00 am and 9:10 am. The Administrator confirmed the other two residents had been picked up to attend the adult day program prior to LPA's arrival. The facility is licensed for four (4) ambulatory residents.

LPA reviewed the residents' files and P & I at 8:45 am until 9:15 am. LPA Spaeth viewed staff files at 9:20 am until 9:55 am. LPA reviewed client's medications at 10:00 am.

LPA Spaeth and the caregiver toured the facility at 10:10 am until 10:45 am.

Common Areas – The living room and family room contained comfortable seating. The dining room contained a dining room table with chairs. The family room contained a television.

Kitchen - LPA Spaeth observed a two day supply of perishable food and a seven day supply of non-perishable foods. The knives and cleaning solutions were securely locked underneath the kitchen sink. The fire extinguisher is located in the kitchen and is operable.

Medication - LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a cabinet.

Continued on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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: DYER ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197608107
VISIT DATE: 03/15/2024
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Water Temperature - The water temperature was tested at 10:35 am and was 107.0 degrees F.

Laundry Room – The laundry room was locked and contained the washer, dryer and laundry detergent.

Garage - The garage was locked and contained the emergency water and an additional freezers.

Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean.

Bathrooms: The bathrooms contained hand soap, wash your hands sign, and trash can.

Hallway Closet - LPA observed clean linens and also contained emergency food.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard.

Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested at 10:50 am and were operable.

There are no deficiencies to report at this time. Exit interview conducted, and a copy of the signed report was given

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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