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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608277
Report Date: 06/13/2022
Date Signed: 06/13/2022 01:44:28 PM


Document Has Been Signed on 06/13/2022 01:44 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:ONE SIMPLE FAMILY, INC.FACILITY NUMBER:
197608277
ADMINISTRATOR:ANNA LIZA CALDERON-MACIASFACILITY TYPE:
735
ADDRESS:44941 13TH STREET WESTTELEPHONE:
(661) 522-7425
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:4CENSUS: 4DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Aniana CalderonTIME COMPLETED:
02:00 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
LPA Spaeth conducted an unannounced annual visit and was greeted by staff member (S1). Upon entering the facility, LPA observed the sign in station. LPA's temperature was taken and LPA answered the COVID questions. LPA observed the sign in station contained hand sanitizer, thermometer, sign in sheet, and face masks. S1 confirmed there are currently four residents and the residents were out shopping for the afternoon with the Administrator, Anna Liza Calderon-Macia.

LPA and S1 began the tour at 12:40 pm. LPA observed the living room/dining room combination which contained comfortable seating, dining room chairs and dining room table, and a television. Each resident has own room and LPA observed two rooms which contained night stand, lamp, chair, bed, linens, chest of drawers and closet. The rooms were neat and clean. LPA observed the two bathrooms which contained wash your hands sign, hand soap, hand dryer, and trash can. Both bathrooms were also clean.

Upon entering the kitchen, LPA observed a four day supply of fresh fruits and vegetables. The freezer section of the refrigerator contained frozen meats. An additional freezer is also located in the kitchen and contained frozen food items. The pantry contained a seven day supply of canned vegetables and other staples. LPA entered the locked staff room and observed the knives were locked in a closet. The washing machine was located in the kitchen.

LPA exited to the backyard and observed comfortable seating available for residents. LPA also observed the pool area was safely locked. The detached garage was unlocked for LPA Spaeth and LPA observed storage items. LPA also observed the side gate was not locked. LPA observed the office area which contained a locked closet supplied with a 90 day supply of PPE items. The resident medications were locked in a file cabinet located in the living room. The hallway closet was locked and contained the cleaning supplies. There are no deficiencies to report at this time. Exit interview was conducted, a copy of the signed report was given to the caregiver.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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 1