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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608281
Report Date: 09/20/2021
Date Signed: 09/20/2021 04:11:55 PM

Document Has Been Signed on 09/20/2021 04:11 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:SHY HOMEFACILITY NUMBER:
197608281
ADMINISTRATOR:HILEWNA TAMRATFACILITY TYPE:
735
ADDRESS:38460 YUCCA TREE STTELEPHONE:
(213) 253-8551
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Hilewana TamratTIME COMPLETED:
03:15 PM
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LPA Spaeth arrived at the facility at 2:00 pm and was greeted by Caregiver Lilliana Ibbarra at the front door. LPA observed the COVID signs on the front door and observed Caregiver was wearing a mask. Upon entering the facility, LPA's temperature was recorded and COVID questions was asked by Caregiver. LPA observed the sign in station at the front entrance which contained sign in sheet, thermometer, masks, and gloves. LPA explained the purpose of the visit was to conduct a annual visit.

LPA Spaeth and Caregiver began the tour in the family room and kitchen at approximately 2:20 pm. LPA observed a resident watching television and observed caregiver, Michelle Gonzalez was assisting a resident. LPA observed caregiver was also wearing a mask. LPA observed the knives were locked in a kitchen drawer and the medications were locked in a kitchen cabinet. LPA observed an adequate supply of frozen foods such as meats and vegetables, fresh fruits and vegetable along with dairy products in the refrigerator. LPA observed an adequate supply of non-perishable canned vegetables and pasta in the pantry. LPA Spaeth observed Caregiver Gonzalez was working with a resident who was drawing at a table in the kitchen.

LPA observed three bedrooms in the facility which all contained lamp, lamp stand, and drawers for storing clothes. There are two bathrooms and LPA was able to observe the wash your hands sign, hand soap, paper towels, and trash can. LPA was then led to the laundry room. LPA observed the laundry soap was locked in a cabinet. LPA Spaeth was then escorted through a locked door to the garage. LPA observed a six month supply of
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SHY HOME
FACILITY NUMBER: 197608281
VISIT DATE: 09/20/2021
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PPE, another freezer which contained frozen meats for use. LPA also observed the emergency water supply. LPA also observed an adequate supply of hygiene items. LPA walked out of the garage to the side of the house and observed the gate that leads to the front door was not locked. LPA also observed comfortable seating available for the residents in the backyard. LPA also observed the facility was neat and clean. The Administrator, Hilewana Tamrat, arrived at 3:00 pm and LPA introduced self to Administrator.

There are no deficiencies at this time. Exit
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
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