197609338-9-26-2022-31-AS-JMAZ-CJMSBK-20220926134403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609338
Report Date: 09/26/2022
Date Signed: 09/26/2022 01:44:49 PM

Document Has Been Signed on 09/26/2022 01:44 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:	B & M CARE FOR ELDERLY INC		FACILITY NUMBER:	197609338
ADMINISTRATOR:	ARAYATA, NATIVIDAD		FACILITY TYPE:	740
ADDRESS:	44851 MARIPOSA DRIVE		TELEPHONE:	(661) 942-2572
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 2	DATE:	09/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Natividad Arayata		TIME COMPLETED:	12:50 PM

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On 09/26/22 at 12:45 p.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and then met with staff and then with Administrator Natividad Arayata. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 12:50 p.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff took LPA’s temperature upon arrival and was asked to sign in. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medications are centrally stored in a locked cabinet in the kitchen area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 1:07 p.m. and appear to be functional. Fire extinguisher was observed to be in charged and with a purchase date of 04/16/22 Common Areas: All common areas were observed to be clean and properly furnished. LPA observed a landline telephone for resident’s use. Resident Rooms: Facility has six (6) bedrooms which of five (5) are designated for resident use. Facility has one live-in staff. All six (6) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are three (3) bathrooms in the facility of which all are for resident’s use. LPA observed all bathrooms to be cleaned. The hot water was tested and measured within regulations. All trash cans located in the bathrooms had tight fitting lids. Showers were observed with grab bars and non-skid mats .

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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: B & M CARE FOR ELDERLY INC	FACILITY NUMBER: 197609338
	VISIT DATE: 09/26/2022

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Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There are no bodies of water. Facility has one shed outside that is used for additional storage. Garage: There is a laundry room that is attached to the garage. This door is kept locked and inaccessible to residents. Garage contains an additional room for staff. This room has the proper permits for the alteration. Permits were shown to LPA during the pre-licensing inspection.

No deficiencies issued. Exit report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

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