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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609346
Report Date: 10/07/2022
Date Signed: 10/07/2022 10:46:39 AM


Document Has Been Signed on 10/07/2022 10:46 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:PALOMAR RESIDENTIAL CARE FACILITIESFACILITY NUMBER:
197609346
ADMINISTRATOR:CABALLERO, SONIAFACILITY TYPE:
740
ADDRESS:45701 17TH STREET WESTTELEPHONE:
(805) 630-3198
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 3DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sonia CaballeroTIME COMPLETED:
10:45 AM
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LPA Spaeth conducted an unannounced annual visit and arrived at 9:45 am. LPA observed the required COVID signs on the front door and was greeted by the Administrator. LPA observed Administrator was wearing a mask and LPA stated the purpose of the visit. Administrator then confirmed there are three residents in the facility.

At 9:47 am, Administrator requested LPA to use automated temperature machine on the wall. LPA observed the sign in station which contained hand sanitizer, and sign in sheet. LPA answered the COVID questions. LPA observed COVID signs posted throughout the facility. LPA also observed a 90-day supply of PPE which was located in the living room and in the locked laundry room.

LPA observed the locked staff room which is the administrator office. LPA observed the living room which contained comfortable seating. Located at the kitchen sink, there was hand soap, wash your hands sign, paper towels, and a trash can. At 10:10 am, the Administrator unlocked a cabinet which contained the resident medications. The cabinet under the sink was locked and contained the cleaning supplies. The knives were locked in a kitchen drawer. The kitchen contained a two-day supply of fresh fruits and vegetables in the refrigerator. The pantry was stocked with a seven-day supply of canned goods.

LPA observed the three residents' room which contained bed, linens, lamp, and night stand. There are two bathrooms in the facility which contained wash your hands sign, paper towels, hand soap, and trash can. The laundry room was locked & contained cleaning supplies, washer and dryer. The side gate leading from the backyard to the front yard was not locked. \LPA observed the facility was neat and clean.

There are no deficiencies to report. Exit interview conducted, appeal rights discussed & report was given to the Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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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