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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609060
Report Date: 12/09/2024
Date Signed: 12/09/2024 04:07:01 PM

Document Has Been Signed on 12/09/2024 04:07 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/
DIRECTOR:		OLOWOSAGBA, SUNDAYFACILITY TYPE:
740
ADDRESS:2049 KALLIOPE AVENUETELEPHONE:
(661) 941-2258
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Sunday OlowosagbaTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 12/09/2024 at 12:40 p.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required Annual Inspection at the facility mentioned above. LPA was greeted by the administrator, Sunday Olowosagba who granted access. LPA explained the reason for the visit. The facility is licensed for six (6) non ambulatory residents of which three (3) may be bedridden with a total capacity of six (6) residents. Facility has a Hospice wavier for 2. The inspection care tool was used to complete the visit.

A physical plant tour was conducted at approximately 12:50 p.m. along with the administrator and LPA observed the following:

Entrance: LPA observed proper postings by the facility entrance.

Common Areas: These include the dining areas, and living rooms. All common areas were observed, clean and clear of clutter. Furniture appeared clean and in good repair. There is an electric fire place not in use properly secured with a screen.

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Knives are kept locked under the kitchen sink, inaccessible to residents in care. Cleaning supplies were observed locked under the kitchen sink. LPA observed there to be sufficient supply of 7-day non-perishable foods and 2-day perishable foods; properly stored. LPA observed a fire extinguisher with a service date of 06/08/2023, fully charged. LPA observed, resident medications will be locked in a kitchen cabinet inaccessible to residents. LPA observed a small refrigerator for medication that requires refrigeration.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. There is appropriate outdoor seating for residents. Auditory alarms were on and functioning at time of visit.

Bedrooms: There are four (4) bedrooms three (3) are designated for resident use. Resident bedrooms are shared. (Continued to LIC809-C)

Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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: TREASURE HERITAGE
FACILITY NUMBER: 197609060
VISIT DATE: 12/09/2024
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(Continued from LIC809) All resident rooms are furnished with required lighting, dresser, chair, bed, linens, and closets for storage. LPA observed a hallway closet with extra linens.

Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in resident's' bedroom for private use. All bathrooms were clean, had grab bars, and trash bins with lids. LPA observed a sufficient supply of hand soup, toilet paper, and paper towels. Hot water temperature has been measured at approximately, 116 degrees Fahrenheit within regulation.

Laundry Room/Garage: Laundry room is kept locked. LPA observed a washer and dryer that appeared operative. LPA observed detergent locked in the laundry room. Through the laundry room is the door to the garage. Garage is used for facility storage.

LPA observed smoke detectors through out the facility, they are interconnected and hard wired. LPA observed a carbon monoxide detector on a wall by the bedrooms. At approximately 12:55 p.m. the administrator tested the smoke alarms and they were observed operational.



Resident file: At approximately 1:02 p.m. LPA conducted a file review of one (1) out of one (1) resident record. LPA reviewed resident record to insure compliance of licensing forms. New resident was admitted Saturday, 12/07/2024. LPA discussed pre-admission procedures, appraisal and needs and services, safeguards for property and valuables and centrally stored medication destruction records (CSMDR) with administrator.

Staff Files / Facility records: At approximately 1:20 p.m. LPA also conducted a file review of one (1) staff record to insure forms and training are up to date and in compliance with licensing forms. LPA found administrator's name on pending administrator certificate list. LPA reviewed infection control plan, liability insurance and emergency disaster plane (LIC610E) with administrator.

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

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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