197608641-11-3-2023-31-AS-MSPH-CX8KCT-20231103074740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608641
Report Date: 11/02/2023
Date Signed: 11/03/2023 07:47:44 AM

Document Has Been Signed on 11/03/2023 07:47 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
WOODLAND HILLS S.ASC, 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:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rex Retolado		TIME COMPLETED:	01:30 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

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by a caregiver and the Administrator. The facility is licensed as an adult residential facility for the elderly to serve three ambulatory residents, three non-ambulatory and one bedridden resident.

LPA reviewed resident's records at 10:10 am until 10:35 am and reviewed staff records at 10:35 am until 11:10 am.

LPA and the Administrator began the tour of the facility at 11:45 am until 12:25 pm. LPA observed the following:

Living Room– LPA Spaeth observed the living room contained comfortable seating and a television.

Kitchen/Dining room - The dining room and kitchen are combined. LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The fire extinguisher is located in the kitchen. LPA observed the knives were locked in a kitchen drawer, and the cleaning solutions were locked in a cabinet underneath the sink. The water temperature was tested at 12:19 pm and the temperature was 107.0 F.

Bathrooms – LPA Spaeth observed the bathrooms contained hand soap, grab bars, paper towels, and a trash can.

Bedrooms – LPA Spaeth observed there are six residents' bedrooms in the facility. The bedrooms contained bed, linens, night stand, chair, chest of drawers, and a night lamp.

Staff Room – LPA observed the staff room was locked.

Cont'd 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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 2

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: PINK CORAL RESIDENCE II	FACILITY NUMBER: 197608641
	VISIT DATE: 11/02/2023

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
26
27
28
29
30
31
32

Laundry Room – LPA Spaeth observed the laundry room was locked and contained a washer and dryer along with the laundry detergent.

Hallway Closet – LPA Spaeth observed the hallway closet contained additional clean linens

Garage - LPA observed PPE supplies and an additional refrigerator with additional food

Backyard – LPA Spaeth observed comfortable seating in a shaded area. A locked gate surrounds the pool. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke/carbon monoxide detectors were tested at 12:15 pm and are operational. .

There are no deficiencies at this time.

Exit interview conducted, and a copy of the signed report was given to caregiver.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2