<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609118
Report Date: 06/14/2024
Date Signed: 06/14/2024 03:58:54 PM


Document Has Been Signed on 06/14/2024 03:58 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:CAPLAND SENIOR LIVINGFACILITY NUMBER:
197609118
ADMINISTRATOR:MANABAT II, EMMANUEL AFACILITY TYPE:
740
ADDRESS:39927 CAPLAND DRIVETELEPHONE:
(661) 480-0082
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 3DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:EMMANUEL MANABAT II,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) Melissa Spaeth conducted an unannounced visit and was greeted by the caregiver. The Administrator, Emmanuel Manabat arrived at 9:30 am. LPA stated the purpose of the visit is to conduct an annual inspection. The facility is licensed for six non-ambulatory of which two may be bedridden. The Administrator confirmed there are three residents.

LPA and the Administrator toured the facility at 9:35 am until 10:00 am

Kitchen - LPA observed a two day supply of perishable food and a seven day supply of non perishable food items. The knives were safely locked in a kitchen cabinet. The cleaning supplies were locked under the kitchen sink.

Common Areas –The living room contained comfortable seating. The dining room contained table and chairs. The family room also contained comfortable seating and a television.

Residents’ Rooms – The rooms contained a bed, linens, night stand, lamp, chest of drawers and a closet.

Bathroom – The two resident bathrooms contained grab bars, slip resistant mats, paper towels and a covered trash can. The staff bathroom was neat and clean and contained the required paper towels and trash can. The water temperature was tested in resident bathroom one at 9:45 am and was 112 degrees F.

Backyard –The backyard contained a covered patio with comfortable seating. The gate leading from the backyard to the front yard was not locked.

Cont’d 809-C

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: CAPLAND SENIOR LIVING
FACILITY NUMBER: 197609118
VISIT DATE: 06/14/2024
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
26
27
28
29
30
31
32
Medications - The medications were locked in the hallway closet. The first aid kit was also locked in the closet.

Laundry Room – The room was locked and contained additional cleaning solutions, the washer and dryer, and laundry detergent



Garage - The garage was locked and contained an additional refrigerator. LPA did not observe any safety issues when viewing the garage.

Egress - There are three exits leaving the facility. LPA observed the egress doors were properly working.


Smoke/Carbon Monoxide Detectors - The smoke/carbon monoxide detectors were tested at 9:55 am and were operable.


Residents’ Records -LPA reviewed residents' records at 10:10 am until 10:30 am.

Staff Records - LPA reviewed NUMBER staff records at 11:00 until 11:20 am.

There are no deficiencies to report at this time.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2