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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608828
Report Date: 10/28/2022
Date Signed: 11/01/2022 07:33:08 AM

Document Has Been Signed on 11/01/2022 07:33 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SVS LANCASTER ADULT DAY PROGRAMFACILITY NUMBER:
197608828
ADMINISTRATOR:LETICIA CAMPBELLFACILITY TYPE:
775
ADDRESS:846 W. LANCASTER BLVD.TELEPHONE:
(661) 729-5954
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 75CENSUS: 0DATE:
10/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Joye Garcia TIME COMPLETED:
11:15 AM
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LPA Spaeth conducted an unannounced visit and was greeted by staff member. Upon approaching the front entrance, LPA observed the required COVID signs on the door. LPA was greeted by the receptionist and LPA's temperature was recorded. LPA was asked to sign in at the designated sign in area. LPA was then greeted by staff member and LPA stated the purpose of the visit was to conduct a tour regarding an incident report. LPA requested resident documentation and received a copy from the staff member. Staff member confirmed there are fifty-three clients who are participating in Zoom meetings and activities in the community.

LPA Spaeth and staff member began the tour at 10:15 am and completed the tour at 10:30 am. LPA observed staff members throughout the building were wearing masks. LPA observed the five bathrooms which contained wash your hands sign, paper towels, hand soap, and a trash can. LPA did not observe any health or safety issues during the tour.

There are no deficiencies to report. Exit interview conducted, and a copy of the signed report was given to the staff member.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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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