197608641-6-10-2022-31-AS-MSPH-CF9TJR-20220610144645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608641
Report Date: 06/10/2022
Date Signed: 06/10/2022 02:46:56 PM

Document Has Been Signed on 06/10/2022 02:46 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:	PINK CORAL RESIDENCE II		FACILITY NUMBER:	197608641
ADMINISTRATOR:	REX RETOLADO		FACILITY TYPE:	740
ADDRESS:	40343 N. 15TH STREET WEST		TELEPHONE:	(661) 480-5985
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 6	DATE:	06/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Rex Retolado		TIME COMPLETED:	02:30 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 arrived at the facility at 12:00 pm and was greeted by the caregiver (S1). LPA's temperature was recorded and LPA answered the COVID screening questions and signed in at the front entrance. LPA was then greeted by Administrator and confirmed there are six residents at the facility. All staff members were wearing masks. LPA and the Administrator began the tour at 12:10 pm. Upon entering the facility, LPA observed the sign in station which contained thermometer, sign in sheet, and hand sanitizer. LPA observed the family room and kitchen combination. LPA observed three residents watching television and sitting in comfortable chairs. Also, LPA observed family members visiting residents and LPA introduced self. LPA observed the six resident bedrooms. All bedrooms contained a bed, linens, chest of drawers, lamp, lamp stand and chair. All rooms were neat and clean. LPA also observed the staff room which was locked. LPA observed the kitchen which contained hand soap, paper towels, and trash can. The locked cabinet underneath the sink contained the cleaning supplies. The knives were locked in a kitchen drawer, and the medications were also locked in a kitchen cabinet. LPA observed a five-day supply of fresh fruits and vegetables in the refrigerator. The freezer section contained frozen meats and vegetables. The pantry contained a seven day supply of canned goods, pasta and rice. The fire extinguisher was located in the kitchen. There are three bathrooms in the facility. All the bathrooms contained sink, hand soap, paper towels, and a trash can. The bathrooms are equipped with grab bars and slip resistant mats in the bathtub and walk-in showers. LPA observed a closet which contained an adequate supply of PPE.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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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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: PINK CORAL RESIDENCE II	FACILITY NUMBER: 197608641
	VISIT DATE: 06/10/2022

NARRATIVE

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LPA was then escorted through a locked door which contained the washer and dryer along with the laundry detergent. LPA then walked through another door which led to the garage. The garage and kitchen pantry contained the emergency supply of food and water. LPA was also escorted to the backyard which contained seating for residents. The pool in the backyard also was locked.

LPA observed a smoke and carbon monoxide combined detectors within the facility. The administrator tested the smoke detectors at 12:45 pm and LPA obaserved the detectors are working. At 1:23 pm, LPA received a copy of the facility's LIC 500 and confirmed all staff members have cleared the background check.

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 Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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