197608107-3-19-2025-31-AS-MSPH-DEWSDR-20250319134731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608107
Report Date: 03/19/2025
Date Signed: 03/19/2025 01:48:23 PM

Document Has Been Signed on 03/19/2025 01:48 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 FACILITY		FACILITY NUMBER:	197608107
ADMINISTRATOR/ DIRECTOR:	BRENDA DYER		FACILITY TYPE:	735
ADDRESS:	40643 CHAMPION WAY		TELEPHONE:	(661) 480-0785
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 4		CENSUS: 4	DATE:	03/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Sharon Maynard and Keith Burns		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the staff member. The facility is licensed for four (4) ambulatory residents. The caregiver confirmed there are four clients.

The Administrator, Brenda Dyer was called at 10:45 am and LPA Spaeth stated the purpose of the visit was to conduct an annual inspection. The Administrator stated they had been in the hospital but have had an adequate number of staff working at the facility The Administrator also stated they have been conducting their duties without any issues. LPA Spaeth received a copy of the staff work schedule.

LPA Spaeth and the staff members. toured the facility at 11:00 am until 11:30 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: 03/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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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Document Has Been Signed on 03/19/2025 01:48 PM - It Cannot Be Edited

Created By: Melissa Spaeth On 03/19/2025 at 12:46 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DYER ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197608107
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above. The water temperature was tested at 11:15 am and was 124.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	The staff member adjusted the water temperature. LPA Spaeth tested the water temperature again at 11:45 am and was 112.5 degrees F.

Type A

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation of the staff records, the licensee did not comply with the section cited above. Staff member #2 had an expired first aid/CPR card which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2025
	Plan of Correction
1 2 3 4	Staff member #2 will complete the first aid/CPR training and send a snapshot of the completed training to LPA Spaeth via text.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Troy Agard

LICENSING EVALUATOR NAME:

Melissa Spaeth

LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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: 03/19/2025

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Water Temperature - The water temperature was tested at 11:15 am and was 124.9 degrees F. The water temperature was adjusted at 11:30 am. LPA tested the temperature at 11:45 am and the temperature was 112.5 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 11: 25 am and were operable.

LPA reviewed the residents' files and P & I at 11:40 am until 12:00pm. LPA Spaeth viewed staff files at 12:00 pm until 12:15 pm. LPA Spaeth observed a staff member’s CPR/First Aid training had expired.

Based upon LPA's observations, the following deficiencies were cited (see 809-D).

Exit interview conducted, appeal rights discussed, and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC809 (FAS) - (06/04)

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