197609325-6-13-2024-31-AS-MSPH-D67TJL-20240613144628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609325
Report Date: 06/13/2024
Date Signed: 06/13/2024 02:47:22 PM

Document Has Been Signed on 06/13/2024 02:47 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:	INDEPENDENT ENTERPRISE HEALTH CARE INC		FACILITY NUMBER:	197609325
ADMINISTRATOR:	JIM DURANDO		FACILITY TYPE:	740
ADDRESS:	36722 ROSE ST		TELEPHONE:	(661) 917-4380
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93552
CAPACITY:	4	CENSUS: 3	DATE:	06/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	JIM DURANDO		TIME COMPLETED:	01:00 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) Spaeth conducted an unannounced visit and was greeted by the Administrator, Jim Durando. LPA stated the purpose of the visit is to conduct an annual inspection. The facility is licensed for two ambulatory and two non-ambulatory residents. LPA confirmed there are three residents in the facility.

LPA and the Administrator toured the facility at 10:00 am until 10:30 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.

Common Areas –The living room contained comfortable seating. The dining room contained table and chairs. The medications are safely locked in a two-drawer cabinet in the dining room.

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

Bathroom – The bathroom contained grab bars, slip resistant mats, paper towels and a covered trash can. The water temperature was tested at 12:35 pm and was 116.0 degrees F.

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

Medications - The medications were locked in a two-drawer cabinet in the dining room. The first aid kit was also locked in the cabinet.

Cont’d 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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: INDEPENDENT ENTERPRISE HEALTH CARE INC	FACILITY NUMBER: 197609325
	VISIT DATE: 06/13/2024

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

Laundry Area – The washer and dryer are located in a laundry area and was locked. The laundry detergent and cleaning solutions were locked in the laundry area.

Egress System -LPA Spaeth observed the egress system was working when exiting the facility.

Smoke/Carbon Monoxide Detectors - The smoke detectors and the carbon monoxide detectors were tested at 10:45 am and were operable. .

Residents’ Records -LPA reviewed residents' records at 10:50 am until 11:15 am and LPA did not observe any issues with the records.

Staff Records - LPA reviewed five staff records at 11:15 pm until 11:45 am.

Based upon LPA's observations, there are no deficiencies.

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

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2