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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608302
Report Date: 12/15/2022
Date Signed: 12/15/2022 01:57:44 PM


Document Has Been Signed on 12/15/2022 01:57 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:LANCASTER HAVEN RCFEFACILITY NUMBER:
197608302
ADMINISTRATOR:MARIA MAXIMA BASCOS, RNFACILITY TYPE:
740
ADDRESS:1755 WEST LANCASTER BLVD.TELEPHONE:
(661) 212-7939
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mildred TrippTIME COMPLETED:
12:45 PM
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LPA Spaeth conducted an unannounced visit to the facility and was greeted by the Administrator. Upon approaching the front door, LPA observed the required COVID signs on the door. Administrator was wearing a mask. LPA observed the sign in station which contained the sign in sheet, thermometer, hand sanitizer, and masks at the front entrance. The Administrator confirmed there are two residents.

LPA and Administrator began tour at 11:35 am until 12:00 noon. LPA was escorted to the dining room and LPA observed a dining room table and chairs. LPA observed the living room contained comfortable seating for the residents. A resident was in the living room and was watching television. LPA observed a 90-day supply of PPE stored the facility.

LPA was then escorted to the kitchen and observed a two day supply of perishable food and a seven day supply of non-perishable food. The freezer section of the refrigerator contained frozen meats. LPA observed wash your hands sign, hand soap, paper towels, and a trash can with a lid in the kitchen. The knives were locked in a cabinet, the cleaning supplies were locked underneath the sink, and medications were also locked in a medication cart which is stored in the kitchen. LPA observed the fire extinguisher in the kitchen.

LPA observed the bathrooms contained wash your hands sign, hand soap, paper towels, non-skid mats and a covered trash can. The outside area contained comfortable seating for residents and the gate surrounding the property was not locked. LPA observed the two residents' rooms which contained bed, linens, lamp stand, lamp and closet. .

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to the Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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