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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608189
Report Date: 08/10/2024
Date Signed: 08/10/2024 03:41:38 PM

Document Has Been Signed on 08/10/2024 03:41 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:PONDERA FAMILY HOMEFACILITY NUMBER:
197608189
ADMINISTRATOR/
DIRECTOR:		SUSAN R. BRUFACILITY TYPE:
735
ADDRESS:602 E. PONDERA STTELEPHONE:
(661) 816-3411
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
08/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Luis Bru Jr - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Luis Bru Jr. and purpose of the visit stated. LPA observed that the four (4) residents were at the facility during visit. This facility is a North Los Angeles Regional Center (NLARC) vendored facility Level II.

A tour of the physical plant was conducted at 12:35 PM and the following was noted:

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted inside. Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the garage and staff room.

The facility is a single storey house and has four (4) bedrooms on two (2) private and one (1) shared bedroom. There are two (2) bathrooms in the facility. One (1) bedroom and one (1) bathroom is designated for staff use. There is no body water in the facility. The facility is fire cleared for four (4) ambulatory residents.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at 118.1°F and within the required range. (continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2024
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: PONDERA FAMILY HOME
FACILITY NUMBER: 197608189
VISIT DATE: 08/10/2024
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary and free of pests. Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable. Laundry area is located in the garage. Knives and sharps are observed to be locked in the medication cabinet along the hallway. All toxins, cleaning agents are also locked in the medication cabinet along the hallway.
Fire extinguisher - There is a fire extinguisher located in the kitchen. Fire extinguisher was observed to be full and last bought on 06/12/24. Smoke alarms were hardwired and inter connected, tested and observed to be operational. There is a carbon monoxide installed in the facility also tested and observed to be operational. Temperature of facility wall thermostat was set at 75°F and observed to be within the required range. Garage is attached to the house and observed to be locked during visit. The garage is also being used as Laundry room, frozen and emergency foods, PPE and laundry soap and other cleaning supplies storage and observed to be locked during visit. There is a shed at the backyard being used as a storage and observed to be locked during visit.

Medication was observed to be inaccessible and stored in a secured medication cabinet along the hallway. There is a complete First Aid kit inside the medication cabinet.


Staff records were reviewed and appeared to be complete and updated. Clients’ records are also reviewed and appeared to be complete and updated.

Disaster drill was last conducted on 08/09/24. Required posting observed in facility (complaint hot line poster, personal rights, etc.).

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2024
LIC809 (FAS) - (06/04)
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