<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608245
Report Date: 12/16/2023
Date Signed: 12/16/2023 02:53:56 PM

Document Has Been Signed on 12/16/2023 02:53 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:LOUISE HOUSE 2FACILITY NUMBER:
197608245
ADMINISTRATOR:JULIANN BARBERFACILITY TYPE:
735
ADDRESS:6455 TUSCAN COURTTELEPHONE:
(661) 526-3983
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 6DATE:
12/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Janine SanchezTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility LPA disclosed to staff the purpose of the visit. Staff revealed the administrator is off on the weekend.

LPA conducted a tour of the physical plant at approximately 11:20 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the living room, dining room and kitchen. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to have adequate seating for residents.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables.

Resident medications and first aid kit box stored in top kitchen cabinet in next to left of microwave. The sharps are stored in bottom kitchen cabinet next to dishwasher. Medications and sharps observed to be locked and inaccessible to residents in care. Toxins are stored and locked in a locked cabinet under kitchen sink.

There is one (1) fire extinguisher on kitchen counter near stove. Fire extinguisher observe to be charged.

Laundry room is located off the kitchen and shares one (1) door with the attached garage. The appliances observed to be clean and functional.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2023
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: LOUISE HOUSE 2
FACILITY NUMBER: 197608245
VISIT DATE: 12/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Cont. from 809)

The facility has a total of four (4) bedrooms and (2) bathrooms. There is no staff room.

The resident bedrooms were properly furnished with at least one chair or chairs available if need, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet next to main (male) bathroom. Shared (female) room with master bathroom have linens stored in bathroom.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 118.0 and 119.0-degrees Fahrenheit.

Backyard has the following: tables and chairs with umbrella available if needed. Patio furniture observed to be in good repair.

Attached Garage: Used for deep freezer storage and for house supplies.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards.

At approximately 1:44 pm, LPA reviewed three (3) random staff files. Staff files contained: Current First aid/CPR and CPI (Crisis prevention) training. Three (3) random resident files reviewed contained: IPP (Individuals Program Plans) and Health assessments.

No Deficiencies cited.

Exit Interview Conducted /Appeals/Copy of the Report given
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2