197609334-12-4-2023-31-AS-CALH-CY7TEL-20231204134006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609334
Report Date: 12/04/2023
Date Signed: 12/04/2023 01:41:44 PM

Document Has Been Signed on 12/04/2023 01:41 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PEOPLE'S CARE GILLESPIE		FACILITY NUMBER:	197609334
ADMINISTRATOR:	LAKESHA BUCHANAN		FACILITY TYPE:	735
ADDRESS:	4021 GILLESPIE RD		TELEPHONE:	(661) 269-2676
CITY:	ACTON	STATE: CA	ZIP CODE:	93510
CAPACITY: 4		CENSUS: 3	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Daniel Morales		TIME COMPLETED:	01:00 PM

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On 12/04/23 at around 09:05 AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – 1 Year Inspection at People’s Care Gillespie and met with staff (S1) Administrator Daniel Morales. LPA explained the purpose of the visit and were accompanied by S1 inside and outside the facility during this inspection.

Facility temp measured at 70 degrees The facility consists of 4 client bedrooms, 1 staff office, 2 bathrooms, a living room, dining room, laundry room and kitchen.

This facility is licensed to serve four adults ages 18 – 59 years. A total of 5 clients are currently residing in this facility, 3 out of 3 clients are ambulatory. A total of 4 staff and one client were present during this inspection.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. Facility has backyard for residents.

3 out of 3 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Alemoh tested hot water temperature in the middle hallway client restroom, and it measured between 116- and 117.1-degrees Fahrenheit. LPA observed hand washing signs in restrooms. This facility provides clients with residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrushes, toothpaste, and comb.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Located in the pantry near the kitchen.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEOPLE'S CARE GILLESPIE	FACILITY NUMBER: 197609334
	VISIT DATE: 12/04/2023

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LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. All Medication and knives are stored in a cabinet in the staff office. Documents are posted as mandated. The last Disaster drill was conducted on 10/11/23. The first aid kit is fully stocked with manual. Smoke and carbon monoxide detectors are hardwired and in compliance and operational. Two (2) Fire Extinguishers were observed throughout the facility purchase date is June 9^th, 2023.

Twelve (12) staff records were reviewed, 12 out of 12 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Three (3) client records were reviewed and 3 out of 3 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. LPA Alemoh reviewed P&I money, 3 out of 3 residents P&I were intact and were not commingled with facility funds or petty cash. All client/resident and staff files are locked in a cabinet in the staff office inaccessible to residents.

No deficiencies cited.

An exit interview was conducted. A copy of this report and appeal rights were discussed and left with Administrator Daniel Morales.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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