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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609335
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:56:58 AM

Document Has Been Signed on 11/01/2022 11:56 AM - 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 MCENNERY CANYONFACILITY NUMBER:
197609335
ADMINISTRATOR:NAZARETH DUENASFACILITY TYPE:
735
ADDRESS:34310 MCENNERY CANYON RDTELEPHONE:
(661) 269-2679
CITY:ACTONSTATE: CAZIP CODE:
93510
CAPACITY: 4CENSUS: 4DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Nazareth Duenas - AdministratorTIME COMPLETED:
12:00 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 Nazareth Duenas and explained the purpose of the visit. LPA observed that three (3) residents were at the facility during visit.

A tour of the physical plant was conducted at 9:45 AM and the following was noted:

The front main door is the only entrance being utilized at the facility. There is a sign on the front door that everyone entering at the facility must be screened. Screening area is located immediately upon 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.

The facility is a single storey home with four (4) private client bedrooms and three (3) bathrooms. One (1) bathroom is designated for the staff and visitors. There is no body 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 measured at a range of 105.6°F to 114.3°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, dining & study room furniture were also checked for functionality (wear and tear). Furniture was 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)
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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: PEOPLE'S CARE MCENNERY CANYON
FACILITY NUMBER: 197609335
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 the a locked storage located near the dining area.

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 74.0°F and observed to be within the required range.
Fire extinguishers. The facility has three (3) fire extinguishers which were last bought 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. Garage was observed to be locked and inaccessible to residents. The garage is also used as a storage for perishable and frozen food, PPE and other supplies.

Client records were reviewed for current IPP’s and/or Needs and Service plans, physician report, admission agreements, etc. Client records appeared to be complete and current.

Medication was observed to be inaccessible to residents and stored in a secured cabinet in the study room. 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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