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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608687
Report Date: 11/29/2022
Date Signed: 11/29/2022 10:55:36 AM


Document Has Been Signed on 11/29/2022 10:55 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:EXCELLENT HOME CARE, LLC IIFACILITY NUMBER:
197608687
ADMINISTRATOR:AMY MORALES FREYFACILITY TYPE:
740
ADDRESS:37208 27TH STREET EASTTELEPHONE:
(661) 949-3740
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:6CENSUS: 2DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Amy MoralesTIME COMPLETED:
11:05 AM
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On 11/29/2022 at 9:20 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA was greeted by Staff #1 (S1) who was wearing a mask and granted access. LPA was asked by S1, Covid-19 screening questions and to sign in. S1 took LPA's temperature. LPA asked staff to call administrator Amy Morales. Amy met us shortly after. LPA explained the reason for the visit. LPA reviewed the Mitigation Plan approved 9/20/2021. The inspection tool was used to complete the visit.

At 9:43 a.m. LPA began a physical plant tour of the facility and following was observed:

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. LPA observed two (2) day perishable and seven (7) day non-perishable foods. Cleaning solutions are locked under the sink. The fire extinguisher was observed in the kitchen and was last serviced on 07/05/2022.

Dining / Living Area: The dining and living area were well lit, clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area is not in use. LPA observed proper Covid-19 signs posted through out the facility. LPA observed the thermostat at a comfortable temperature of 75°F

Bedrooms: There are four (4) bedrooms designated for resident use. Two (2) out of the four (4) rooms are vacant. Two (2) out of the four (4) are in use by residents. The resident rooms are furnished with required lighting, dresser, chair, bed, and linens. There was an extra supply of linens in a hallway closet.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EXCELLENT HOME CARE, LLC II
FACILITY NUMBER: 197608687
VISIT DATE: 11/29/2022
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Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in a resident's bedroom and the other main bathroom is accessible to all the residents. Both bathrooms were well lit, clean, had grab bars and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels. At 9:55 a.m. water temperature in the main bathroom was measured at 113.4 degrees Fahrenheit.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gates on either side of the house were closed but unlocked. There is a covered patio to provide shade and appropriate outdoor seating for residents.

Medications/ Resident file: LPA observed, resident medications and resident files locked in a hallway closet inaccessible to residents.

LPA observed smoked alarms through out the facility. Smoke alarms are dual carbon monoxide and hard wired. At 10:00 a.m. all smoke alarms were tested and functioned properly. Administrator states the facility has enough PPE for 30 days.



No deficiencies were observed during todays visit and the facility is currently following their infection control plan.

Exit interview conducted and a copy of this report issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
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