197609319-1-20-2022-31-AS-SSTS-CAUTKN-20220120134813

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609319
Report Date: 01/20/2022
Date Signed: 01/20/2022 01:48:38 PM

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:	A MORNING STAR VILLA		FACILITY NUMBER:	197609319
ADMINISTRATOR:	NELSON,JABON M		FACILITY TYPE:	740
ADDRESS:	23656 VIA DELOS		TELEPHONE:	(818) 294-3410
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 6	DATE:	01/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Nelson Jabon, Administrator		TIME COMPLETED:	02:00 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) Shira Stamps, met with Administrator Nelson Jabon for an unannounced one (1) year Required visit for this facility. LPA arrived at 12:40 pm and was greeted by the Administrator. Two (2) residents were observed in the living room watching TV. The rest of the residents were observed to be in their room sleeping and/or resting. LPA informed the Administrator of the purpose of the visit. Infection control: LPA Stamps reviewed facility mitigation plan (approved on 03/25/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the Administrator and asked all infection control questions. LPA was asked to sign-in and sanitize/wash hands. A physical plant tour was conducted with the Administrator at 12:47 pm. The facility has five (5) bedrooms and three (3) bathrooms currently occupying six (6) residents. One (1) bedroom and one (1) bathroom is designated for staff use only. The facility is Fire Cleared for five (5) non- ambulatory and one (1) bedridden. Resident Rooms LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each resident. LPA tested the exit doors auditory system, and it was observed to be operational for each room. Bathrooms At 1:00 pm LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 1:05 pm and measured within regulation at 117.0 degrees F.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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: A MORNING STAR VILLA	FACILITY NUMBER: 197609319
	VISIT DATE: 01/20/2022

NARRATIVE

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Food Inspection
LPA conducted a tour of the kitchen around 12:47 pm and observed there to be sufficient stock of two day perishables and seven day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. Medications were observed to be locked in the hallway cabinet.

Physical environment
LPA toured the outside area of the facility at 12:55 pm. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 12:58 pm. There are two (2) fire extinguishers, one (1) is located in the kitchen and one (1) is located in the garage. Both Fire extinguishers were observed to be full and last serviced on 12/02/21.

Garage
LPA observed the garage to be attached to the facility and currently being used for extra food storage, PPE supplies and the laundry area. All chemicals/hazardous items were observed to be locked in a cabinet at approximately 1:06pm.

Administrative: LPA collected the resident roster and LIC.500. Annual fee is current.

An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC809 (FAS) - (06/04)

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