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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609334
Report Date: 11/01/2022
Date Signed: 11/08/2022 04:55:11 PM

Document Has Been Signed on 11/08/2022 04:55 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:PEOPLE'S CARE GILLESPIEFACILITY NUMBER:
197609334
ADMINISTRATOR:LAKESHA BUCHANANFACILITY TYPE:
735
ADDRESS:4021 GILLESPIE RDTELEPHONE:
(661) 269-2676
CITY:ACTONSTATE: CAZIP CODE:
93510
CAPACITY: 4CENSUS: 4DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Amparo Purvin - AdministratorTIME COMPLETED:
03:15 PM
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A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Amparo Purvin and explained the purpose of the visit. LPA observed that all four (4) residents were at the facility during visit.

A tour of the physical plant was conducted at 12:45 PM and the following was noted:

The garage door is the only entrance being utilized at the facility. There is a sign on the door that everyone entering at the facility must be screened. Screening area is located in the garage immediately before entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask.

The facility had submitted and approved Mitigation and Infection Control Plan.

Facility has four (4) private client bedrooms and two (2) bathrooms. One (1) bathroom is designated for the staff and visitors. There is a designated office area where they keep the files and medication. There is no body of water in the facility.
Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at 118.3°F and within the required range.
Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living, family & dining rooms furniture were also checked for functionality (wear and tear). Areas were clean and furniture were observed to be in good condition.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEOPLE'S CARE GILLESPIE
FACILITY NUMBER: 197609334
VISIT DATE: 11/01/2022
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(continued from LIC 809)

Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet below the kitchen sink. Knives and sharps are kept in a locked kitchen drawer.

Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is set at 75.0°F and observed to be within the required range.

Fire extinguishers. The facility has four (4) fire extinguishers which were last checked on 01/25/22. Carbon monoxide and smoke alarms are hardwired and interconnected, tested and observed to be operable.

Garage is attached to the house and access has to go through the Laundry room. Laundry detergents and other toxins were locked in the cabinet in the laundry run. Garage was being utilized as the main entrance for Covid-19 protocol reasons. The garage is also used as a storage for PPE and frozen and emergency food storage. There is a patio in the backyard area with outdoor furniture for residents' use.

Client records were reviewed for current IPPs and/or Needs and Service plans, physician report, admission agreements, etc. Residents' file appeared to be complete and updated.

Medication was observed to be inaccessible to residents and stored in a secured cabinet in the office area. There is a complete First Aid kit in the medication cabinet.

Staff records were reviewed. Staff present records were observed to be current and updated.

Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
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