197608687-3-13-2024-31-AS-MSPH-D3BUV5-20240313155431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608687
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:55:11 PM

Document Has Been Signed on 03/13/2024 03:55 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EXCELLENT HOME CARE, LLC II		FACILITY NUMBER:	197608687
ADMINISTRATOR:	AMY MORALES FREY		FACILITY TYPE:	740
ADDRESS:	37208 27TH STREET EAST		TELEPHONE:	(661) 949-3740
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY:	6	CENSUS: 5	DATE:	03/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	AMY MORALES FREY		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator Amy Frey. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are five residents. The facility is licensed for five (5) non-ambulatory residents and one bedridden resident.

LPA Spaeth reviewed the resident and staff files at 1:10 pm until 1:50 pm. LPA reviewed the medications at 1:50 pm until 2:00 pm.

LPA Spaeth and the Administrator toured the facility at 2:00 pm until 2:30 pm.

Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room area contained a dining room table and chairs.

Kitchen - LPA Spaeth observed a two-day supply of perishable food and a seven day supply of non-perishable food. The knives were securely locked in a kitchen drawer. The cleaning solutions were locked underneath the kitchen sink. The fire extinguisher is located in the kitchen and is operable.

Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a hallway closet.

Garage – The garage was locked and contained the washer/dryer and laundry detergent. The emergency food and water are also located in the garage.

Continued on 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EXCELLENT HOME CARE, LLC II	FACILITY NUMBER: 197608687
	VISIT DATE: 03/13/2024

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Resident Rooms: There are four resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean.

Bathrooms: There are two (2) bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, trash can, and slip resistant mats. The water temperature was recorded to be 111.0 Degrees F at 2:20 pm.

Additional Hallway Closet - LPA observed the clean linens were located in a cabinet.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard.

Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested at 2:25 pm and were operable.

There are no deficiencies to report at this time.

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

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

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