197609016-7-13-2024-31-AS-JGTN-D75QEJ-20240713120626

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609016
Report Date: 07/13/2024
Date Signed: 07/13/2024 12:06:32 PM

Document Has Been Signed on 07/13/2024 12:06 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:	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:	07/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Richard Mandac - Co Administrator		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Gary Tan, met with Administrator Richard Mandac for a one (1) year required visit for this facility. Purpose of the visit was stated. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan. Signs of Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. A tour of the physical plant was conducted with Mr. Mandac at 9:123 AM. The facility has five (5) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom and one (1) bathroom is designated for staff use only. The facility is fire cleared for six (6) non-ambulatory residents, one of which maybe bedridden. Hospice waiver for two (2) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 76°F. Dual smoke/carbon monoxide detector is hardwired, tested and observed to be operational. There was a fire extinguisher located in the bedroom hallway. Fire extinguisher was observed to be full and last inspected on 05/16/24. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024

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: ARK CARE HOME LLC	FACILITY NUMBER: 197609016
	VISIT DATE: 07/13/2024

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(continued from LIC 809)

The garage is attached to the home and also being used as storage for frozen and emergency food and old equipment. The garage is observed to be locked and inaccessible to residents. Laundry room is located along the bedroom hallway going to the garage. Laundry detergents, cleaning solutions and other chemicals and toxins are locked and secured in the garage.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Dishwashing liquids and other cleaning supplies were stored in the garage. All sharps and knives were also observed to be locked in the medication cabinet.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit to non-private rooms. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Room: Staff room is observed to be locked. No medications are observed in the staff room. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at 111.2.°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in the medication cabinet located in the bedroom hallway to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the bedroom hallway.
Client records: Client records are reviewed and appeared to be complete and updated. Staff records: LPA also conducted a complete file review of staff records. Staff record appeared to be complete and updated.

Disaster drill was last conducted on 07/01/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024

LIC809 (FAS) - (06/04)

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