197609016-5-19-2022-31-AS-APAA-CEKP6N-20220519110237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609016
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:04:16 AM

Document Has Been Signed on 05/19/2022 11:04 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:	ARK CARE HOME LLC		FACILITY NUMBER:	197609016
ADMINISTRATOR:	MANDAC, ADELAIDA Q		FACILITY TYPE:	740
ADDRESS:	37616 RIBBON LANE		TELEPHONE:	(661) 526-4066
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93552
CAPACITY:	6	CENSUS: 3	DATE:	05/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Adelaida Mandac, Administrator		TIME COMPLETED:	11:25 AM

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At 9:30am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Administrator, who granted access to the facility. Reason for the visit was explained.

LPA conducted a physical tour with the Administrator and observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 03/06/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff.

Kitchen: At approximately, 09:50am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked under the kitchen sink and inaccessible to residents in care. Fire extinguisher was last serviced on 02/18/2022.

Medications: At approximately, 10:15am LPA observed medications are centrally stored and locked in the cabinet located in a staff room and inaccessible to residents in care.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARK CARE HOME LLC	FACILITY NUMBER: 197609016
	VISIT DATE: 05/19/2022

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Bathrooms: At 10:20am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 105.0°F. LPA observed appropriate grab bars and showers had non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom.

Common Areas: The facility maintains a comfortable temperature at 78°F. The living room and dining area appeared clean and were properly furnished and the fireplace is adequately screened. Laundry area is located in a hallway and LPA observed all cleaning and laundry detergents locked and inaccessible to residents.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:30am they were tested and observed to be operational.

Outside areas: At approximately, 10:35am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Administrative: LPA collected Certificate of Liability Insurance, and LIC.500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC809 (FAS) - (06/04)

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