197609015-11-2-2022-31-AS-ERIS-CKSQ5A-20221102115139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609015
Report Date: 11/02/2022
Date Signed: 11/02/2022 11:52:08 AM

Document Has Been Signed on 11/02/2022 11:52 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 LLC		FACILITY NUMBER:	197609015
ADMINISTRATOR:	AMORSOLO-SAMANIEGO, MARITA		FACILITY TYPE:	740
ADDRESS:	4144 VAHAN COURT		TELEPHONE:	(661) 794-9940
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 6	DATE:	11/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Marita Sameniego		TIME COMPLETED:	12:00 PM

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On 10/18/2022 at 10:18 a.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at the facility mentioned above. LPA was greeted by Staff #1 (S1) who granted access to the facility. Upon entry LPA was asked by S1 to sign-in. S1 then left LPA to sign-in and returned to attend to the residents in the kitchen. Administrator Marita Sameniego met us shortly after. Informed Administrator of the purpose of the visit. At approximately, 10:20 a.m. a physical tour was conducted with the Administrator and LPA observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 03/14/2021) to make sure licensee was following current infection control recommendations. Proper signs were observed inside along the the entry. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: LPA toured the kitchen area and observed enough supplies of staple non-perishable for 7 days and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. Fire extinguisher located in the kitchen had a purchase receipt of 01/16/2022 and observed to be fully charged.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:40 a.m. they were tested and observed to be operational.

Bedrooms: There are seven (7) bedrooms five (5) of which are designated for residents use and have sufficient lighting. All resident bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: LPA observed all three (3) bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 114.°F. LPA observed appropriate grab bar and non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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: CARING HEARTS SENIOR CARE HOME LLC	FACILITY NUMBER: 197609015
	VISIT DATE: 11/02/2022

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Entry Living area: LPA observed entry living area to be clean and free of clutter. Furniture appeared to be clean and in good repair.

Dining area/ Living Room 2: LPA observed a dining table with seating. Area was clean and clear of clutter. Dining table and chairs appeared to be in good repair. First Aid kit was observed in the dining area. LPA observed a second living room clean and clear of clutter and furniture appeared to be in good repair. LPA observed a fireplace in the living room closed and not in use.

Laundry room: LPA observed door to laundry room locked. Chemicals and detergents are kept in laundry room locked.

Outdoor areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture. LPA observed a shed being used for storage locked. There are no bodies of water. LPA observed two side gates closed and not locked.

No deficiencies cited / A copy of this report was provided/ Exit interview conducted.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC809 (FAS) - (06/04)

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