197609346-11-22-2021-31-AS-MSPH-C8ZS5X-20211122123504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609346
Report Date: 11/22/2021
Date Signed: 11/22/2021 12:36:33 PM

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:	PALOMAR RESIDENTIAL CARE FACILITIES		FACILITY NUMBER:	197609346
ADMINISTRATOR:	CABALLERO, SONIA		FACILITY TYPE:	740
ADDRESS:	45701 17TH STREET WEST		TELEPHONE:	(805) 630-3198
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	6	CENSUS: 3	DATE:	11/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Sonia Caballero		TIME COMPLETED:	12:45 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	LPA Spaeth conducted an unannounced annual visit and arrived at the facility at 11:10 am. LPA observed the required COVID signs on the front door and was greeted by caregiver May Baulus. Caregiver greeted LPA and was wearing a mask. The caregiver asked COVID questions, took LPA's temperature, and requested LPA to sign in. LPA observed the sign in station which contained PPE supplies, gloves, hand sanitizer, and mask along with the sign in sheet at the front door. Caregiver confirmed there are three non-ambulatory residents, four bedrooms, and two bathrooms. LPA observed the living room which contained comfortable furniture and was escorted to the family room, dining room and kitchen combination. LPA observed a resident sitting in a chair watching television. The Administrator, Sonia Caballero then arrived at 11:20 am. LPA and the Administrator began the tour of the facility at 11:25 am. LPA observed the locked staff room which is the administrator office. The family room was neat and clean which contained comfortable seating and a television. Within the kitchen, there was hand soap, wash your hands sign, paper towels, and a trash can at the sink location. At 11:35 am, the Administrator unlocked a cabinet which contained the resident medications. Administrator then unlocked another cabinet which contained resident records and a 90 day supply of PPE. The cabinet under the sink was locked; Administrator unlocked the cabinet which contained the cleaning supplies. The refrigerator contained an adequate supply of fresh vegetables, fresh fruit, and dairy products. The freezer contained frozen meats. The pantry was stock was non-perishable canned goods. LPA was escorted to the back yard which contained comfortable furniture and LPA observed the gate leading to the front yard was not locked.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

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: PALOMAR RESIDENTIAL CARE FACILITIES	FACILITY NUMBER: 197609346
	VISIT DATE: 11/22/2021

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When escorted to the north side of the facility, LPA observed the linen closet which was fully supplied with clean linens for the residents. LPA observed the resident rooms were neat and clean. Each room contained a bed, linens, lamp, lamp stand, and chest of drawers.

Each bathroom contained wash your hands sign, slip-resistant mat, hand soap, paper towels, and trash cans. LPA observed the bathrooms were neat and clean. LPA was then escorted to the locked laundry room which contained washer and dryer. The laundry room contained laundry soap. The laundry room leads to the garage and LPA observed additional PPE in the garage.

There are no deficiencies to report at this time. Exit interview was conducted, appeal rights discussed, and a copy of the report was given to the Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

LIC809 (FAS) - (06/04)

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