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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608277
Report Date: 07/13/2024
Date Signed: 07/13/2024 03:56:25 PM

Document Has Been Signed on 07/13/2024 03:56 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:ONE SIMPLE FAMILY, INC.FACILITY NUMBER:
197608277
ADMINISTRATOR/
DIRECTOR:		ANNA LIZA CALDERON-MACIASFACILITY TYPE:
735
ADDRESS:44941 13TH STREET WESTTELEPHONE:
(661) 522-7425
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: 4DATE:
07/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:48 PM
MET WITH:Anne Calderon - Co AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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A Required Annual visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with the Administrator Annie Calderon. This is a North Los Angeles Regional Center vendored facility level 2.

At 12:55 PM, A tour of the physical plant was assessed and the following was noted:

The only entrance being utilized is the main front door 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 outside the doors. 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 front and backyard. The facility has sufficient stock of PPE in the storage room.

The facility has four (4) private client bedrooms and two (2) bathrooms. There is one (1) additional bedroom designated for staff use and another room used as an office. The swimming pool is appropriately fenced and observed to be locked during visit.

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 115.7°F and within the required range.

(continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2024
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: ONE SIMPLE FAMILY, INC.
FACILITY NUMBER: 197608277
VISIT DATE: 07/13/2024
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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. All the toxins, cleaning solutions and disinfectants are locked in the cabinet along the bedroom hallway.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is set at 75°F and observed to be within the required range.
Fire extinguisher There is a fire extinguisher located in the dining area. Extinguisher was observed to be full and last bought on 10/09/23. Dual smoke alarms/carbon monoxide are tested and observed to be operational. Garage is detached to the house and observed to be locked during visit. The garage is also use for storage of old equipment and tools.

Client records. All four (4) clients record were reviewed for current IPP and/or Needs and Service plans. physician report, admission agreements and P & I funds. Client records appeared to be complete and current. Staff records were reviewed. Staff has criminal record clearances and associated to this facility. Staff records appear to be complete and current.



Medication was observed to be inaccessible and stored in a secured cabinet located near the dining room. Medication records and procedures reviewed with staff. There is a complete First Aid kit located in the kitchen.

Disaster drill was last conducted on 07/01/24. Required posting are observed to be complete and current and displayed properly at the facility.

There is no health and safety issue during this visit. Exit interview conducted. Copy of this report issued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024
LIC809 (FAS) - (06/04)
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