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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609060
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:16:03 PM


Document Has Been Signed on 12/07/2022 02:16 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:TREASURE HERITAGEFACILITY NUMBER:
197609060
ADMINISTRATOR:OLOWOSAGBA, SUNDAYFACILITY TYPE:
740
ADDRESS:2049 KALLIOPE AVENUETELEPHONE:
(661) 941-2258
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Sunday OlowosagaTIME COMPLETED:
02:30 PM
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On 12/07/2022 at 12:40 p.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff #1 (S1) who was wearing a mask and granted access to the facility. S1 called administrator Sunday Olowosaga and Administrator met us shortly after. LPA explained the reason for the visit.

A physical tour was conducted at 12:45 p.m. and LPA observed the following:

Infection control: LPA was prompted by S1 to sign-in the visitor’s log. LPA observed hand sanitizer was available upon entrance. A fire extinguisher was observed by the front door with a service tag, last serviced 03/21/2022

Common Areas: These include the dining areas, and two (2) living rooms. All common areas were observed well lit and clean. LPA observed books and puzzles on the tables available for residents to use. Furniture appeared clean and in good repair. There is an electric fire place in one (1) of the living rooms. LPA observed the thermostat at a comfortable temperature of 74°F.

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances appeared operative. Knives and cleaning supplies are kept locked in a kitchen cabinet inaccessible to residents. LPA observed there to be sufficient stock of 7-day non-perishable foods and 2-day perishable foods. A 2nd fire extinguisher was observed in the kitchen with a service tag, last serviced on 03/21/2022.

Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in one (1) of the shared bedrooms and the other bathroom is located in the hallway outside the three bedrooms accessible to all the residents. Both bathrooms were well lit, clean, had grab bars, and had hand washing signs. LPA observed a sufficient supply of hand soup and paper towels. At approximately 1:04 p.m. water temperature in one (1) out of the two (2) bathrooms was measured at 105°F.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
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: TREASURE HERITAGE
FACILITY NUMBER: 197609060
VISIT DATE: 12/07/2022
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Bedrooms: There are three (3) bedrooms designated for resident use. Two (2) out of the three (3) bedrooms are shared bedrooms. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens.

Laundry Room/Garage: Laundry room is kept locked. LPA observed a washer and dryer that appeared operative. Detergents are kept in a cabinet above the washer and dryer. Through the laundry room is the door to the garage. The garage was observed to store, PPE and two (2) fridges with resident's food.

Medications/ Resident file: LPA observed, resident medications locked in a kitchen cabinet inaccessible to residents. Resident files were observed in a filing cabinet located in one (1) of the dining areas.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gate on side of the house was closed but unlocked.

LPA observed smoke alarm through out the facility, they are interconnected and hard wired. At 12:54 p.m. all smoke alarms were tested and functioned properly. LPA observed one carbon monoxide alarm in the hallway that appeared operational.



No deficiencies were observed during todays visit. Exit interview conducted and a copy of this report issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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