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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609293
Report Date: 08/17/2022
Date Signed: 08/17/2022 02:42:48 PM

Document Has Been Signed on 08/17/2022 02:42 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:16TH STREET HOME CARE INCFACILITY NUMBER:
197609293
ADMINISTRATOR:MACIAS, OSCARFACILITY TYPE:
735
ADDRESS:44920 16TH STREET WESTTELEPHONE:
(661) 373-3223
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: 3DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Aniana CalderonTIME COMPLETED:
12:30 PM
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LPA Spaeth arrived at the facility at 11:30 am and observed the COVID sign on the front door. LPA was greeted at the door by caregiver for the facility who confirmed there are three residents. LPA also observed the COVID signs posted at the front entrance and in the living room. LPA observed staff member was wearing a mask. LPA began tour by entering the kitchen and observed wash your hands sign, hand soap, paper towels, and trash can. LPA observed an adequate supply of fresh food items in the refrigerator (vegetables and fruits). The freezer contained an adequate supply of frozen foods. LPA observed the pantry contained a a7-day supply of canned goods and the pantry was well organized. The hallway closet was unlocked and LPA observed PPE supplies, resident medications, first aid kit, and hygiene items. LPA observed the two bathrooms which contained wash your hands sign, hand soap, slip resistant mat, paper towels, and a trash can. LPA Spaeth observed a resident's room which was adequately furnished with lamp, lamp stand, bed, and linens. Aniana Calderon arrived at 12:05 pm and greeted LPA Spaeth.

LPA Spaeth observed the dining room and family room are combined and there was comfortable seating available for residents. LPA was escorted to the other side of the building which contained a bathroom and three resident rooms. LPA also observed the facility was neat and clean. LPA went in the backyard and observed covered area which contained comfortable seating to be used by the residents. The side gate that leads to the front yard was not locked and is available for use in case of an emergency.

There are no deficiencies to report at this time. Exit interview, appeal rights discussed. LPA confirmed a copy of the signed report will be emailed to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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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