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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609118
Report Date: 06/24/2022
Date Signed: 06/24/2022 02:30:01 PM


Document Has Been Signed on 06/24/2022 02:30 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:CAPLAND SENIOR LIVINGFACILITY NUMBER:
197609118
ADMINISTRATOR:MANABAT II, EMMANUEL AFACILITY TYPE:
740
ADDRESS:39927 CAPLAND DRIVETELEPHONE:
(662) 480-0082
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 6DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Virginia LabaoTIME COMPLETED:
02:30 PM
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LPA Spaeth conducted an unannounced visit to the facility and was greeted by caregiver. LPA observed a caregiver in the kitchen washing dishes. Both caregivers were wearing a mask. Upon entering the facvility, LPA observed family members visiting with a resident in the living room. LPA’s temperature was recorded and LPA also answered the COVID questions. LPA observed the sign in station which contained thermometer, hand sanitizer, and sign in sheet with COVID questions.

Living Room Area - LPA observed comfortable seating in the living room. The room was spacious and very clean.

Family Room/Kitchen/dining room Area - LPA observed three residents watching television in the family room and observed the dining room area contained a dining room table and chairs. The family room is spacious and contained comfortable seating. LPA observed the sink area contained wash your hands sign, hand soap, and paper towels. The cleaning supplies were locked under the kitchen sink. The knives were safely locked in a kitchen cabinet. LPA observed the refrigerator contained a five-day supply of fresh fruits and vegetables, eggs, and other dairy products. The freezer contained frozen meats and vegetables. The pantry was neat and well-stocked with a seven-day supply of canned goods and other dry good items.

Backyard area -LPA observed a shaded area in the backyard which contained comfortable seating. The side gate was not locked that leads from the backyard to the front yard. The backyard was also neat and clean.

Hallway area - LPA observed a linen closet which contained clean linens, an adequate supply of PPE items, and diapers. The medications were locked in the hallway cabinets.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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: CAPLAND SENIOR LIVING
FACILITY NUMBER: 197609118
VISIT DATE: 06/24/2022
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Residents' Rooms- There are five resident rooms. Each room contained bed, linens, chest of drawer, closet, night lamp, night stand and a chair. Each room was neat and clean. The staff room was locked.

Locked Laundry Area - LPA observed the locked laundry area which contained laundry detergent, washer and dryer. A door within the room led to the garage which contained additional storage items and an additional refrigerator which contained eggs and frozen meats.



Bathrooms - There are three bathrooms in the facility. The bathrooms contained wash your hands sign, hand soap, paper towels, non-skid mat, and a trash can.

There are no deficiencies to report at this time. Exit interview was conducted, appeal rights discussed and LPA gave a copy of the report during the visit.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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