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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609015
Report Date: 11/22/2024
Date Signed: 11/22/2024 11:57:31 AM

Document Has Been Signed on 11/22/2024 11:57 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:CARING HEARTS SENIOR CARE HOME LLCFACILITY NUMBER:
197609015
ADMINISTRATOR/
DIRECTOR:		AMORSOLO-SAMANIEGO, MARITAFACILITY TYPE:
740
ADDRESS:4144 VAHAN COURTTELEPHONE:
(661) 794-9940
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Jezrael Teriote/ CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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On 11/22/2024 at 8:40 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA met with Jezrael "Jesse" Teriote, and explained the purpose of the visit. Jesse requested LPA sign in and then contacted the administrator, Marita Samaniego. According to Jesse the administrator may meet LPA later, but was currently attending training. The facility is a licensed Residential Care Facility for the Elderly (RCFE), with a capacity of six (6) non-ambulatory residents of which one (1) may be bedridden. The facility also has a Hospice waiver for two (2) residents. Required postings were observed upon entry.

At approximately 8:45 a.m., with the assistance of staff, LPA took a tour of the physical plant and the following was observed:

Common Areas: These included the sitting area, living room and dining area. The sitting area was clean and clear of clutter, furnished with couches and chairs to sit the capacity of the facility. The living room is furnished with couches, recliners, a television and fireplace secured with a screen. The dining room has a table with chairs large enough to seat six (6) comfortably. Furniture was observed to be in good repair. Hallways, entry and exits were clear of any obstructions.

Kitchen: The kitchen was observed to have a refrigerator, stove/oven, dishwasher and microwave. Fixtures and appliances were observed functional. LPA observed a sufficient amount of 2-days perishable and 7 -days non-perishable food in the facility; properly stored. Knives were observed locked in a kitchen drawer. Centrally stored medication was observed locked in a kitchen cabinet. A fully charged fire extinguisher was observed on a kitchen wall with purchase date 03/04/2024. Medication requiring refrigeration was observed in a locked box in the fridge. LPA observed a fully stocked first aid kit and manual accessible to staff in the kitchen. (Continued on LIC809-C)
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARING HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 197609015
VISIT DATE: 11/22/2024
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Bedrooms: There are five (5) total resident bedrooms of which one (1) may be shared. LPA observed each resident room to be properly furnished with appropriate beddings and linens and sufficient lighting. Exit doors had auditory alarms that were observed functioning.

Bathrooms: The facility has three bathrooms with walk-in showers. Bathrooms were properly supplied with hand soap, toilet paper and paper towels. Hot water temperature in the bathrooms were tested at 9:00 a.m. and measured 116 degrees Fahrenheit, within regulation.

The facility is equipped with hardwired smoke and carbon monoxide detectors through out the facility. LPA observed staff test alarms at approximately 9:05 a.m. and were observed to be functioning.

Surrounding Grounds: Backyard space was large enough for outdoor activities. There is a covered patio with outdoor furniture. A shed used for extra facility storage was observed locked. The gates on both sides of the home were checked to insure no locks were installed, and that exits and passageways were clear for emergency evacuation.

Laundry Room: The laundry room was observed locked and leads to staff bedrooms. Cleaning supplies and detergents were locked in cabinets and in the laundry room.

Client/Staff Records: At approximately 9:30 a.m, facility, resident and and staff records were reviewed to insure compliance. LPA reviewed resident roster, personnel report, liability insurance certificate, infection control plan, emergency and disaster plans and drills. At 10:21 a.m. LPA reviewed four (4) of four (4) resident records and three (3) staff records.

Medications: At 11:20 a.m. LPA reviewed medication and Centrally Stored Medication Destruction Records for compliance.

LPA spoke to Administrator, Marita Samaniego by telephone. Marita designated Jesse to sign today's report.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted. A Copy of the report issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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