197608687-10-30-2024-31-AS-MSPH-DAJV7R-20241030161130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608687
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:20:54 PM

Document Has Been Signed on 10/30/2024 04:20 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/ DIRECTOR:	AMY MORALES FREY		FACILITY TYPE:	740
ADDRESS:	37208 27TH STREET EAST		TELEPHONE:	(661) 949-3740
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	10/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Amy Moarales Frey		TIME VISIT/ INSPECTION COMPLETED:	01:40 PM

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregivers. The Administrator Amy Frey arrived at 10:15 am. 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 and the Administrator toured the facility at 10:30 am until 11:05 am.

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 locked. 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.

Continued on 809-C

Troy Agard	TELEPHONE: (818) -596-4334
Melissa Spaeth	TELEPHONE: (818) 421-2278
	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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: 10/30/2024

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Garage/Staff Room – The door leading into the staff room and garage area was not locked. LPA observed the washer/dryer are located in the garage and additional cleaning solutions along with the laundry detergent were stored in the garage. During LPA's tour, the door leading to the area was locked by staff.

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.

Water Temperature: The water temperature was recorded to be 105 Degrees F at 10:15 am.

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 11:40 am and were operable.

LPA Spaeth reviewed the resident files at 11:40 am until 12:15 pm and reviewed the staff staff files at 12:15 pm until 12:45 pm. LPA reviewed the medications at 1:05 pm until 11:15 pm.

The following deficiency was issued.

Exit interview conducted, appeal rights discussed, 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: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/30/2024 04:20 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above. LPA Spaeth observed cleaning solutions and laundry detergent were not safely locked in the garage which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2024
	Plan of Correction
1 2 3 4	During LPA's visit, LPA observed the garage was locked.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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