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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608281
Report Date: 09/26/2022
Date Signed: 09/26/2022 11:16:24 AM

Document Has Been Signed on 09/26/2022 11:16 AM - 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:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:liliana IbarraTIME COMPLETED:
09:00 AM
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 visit and was greeted by two caregivers and both were wearing masks. LPA's temperature was recorded, and COVID questions were asked. LPA observed the sign in station at the front door which included the sign in sheet, thermometer, hand sanitizer and masks. LPa observed COVID signs on the front door and throughout the facility. When conducting the tour, LPA observed the entire facility was neat and clean.

The residents' rooms contained a bed, linens, night stand, and lamp. LPA observed caregiver was cleaning the resident's rooms. The master bedroom contained two resident beds and were six feet apart. The master bedroom also contained a bathroom which contained wash your hands sign, hand soap, paper towels, and a trash can. The second bathroom was being used by a resident but caregiver stated the second bathroom contained all the required items (hand soap, etc).

The kitchen was clean and the sink area contained hand soap, paper towels, and a trash can. The cleaning supplies were locked underneath the sink and the resident medications were locked in a kitchen cabinet. The knives were also locked in a drawer in the kitchen. LPA observed a two-day supply of fresh fruits and vegetables and a seven day supply of canned goods.

LPA observed the laundry room and the laundry supplies were securely locked in a cabinet. The Caregiver unlocked the garage and LPA observed PPE supplies, an additional refrigerator, and additional canned goods.
The backyard contains lawn furniture and the side gate that leads from the backyard to the front yard was not locked.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the report was given to the caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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