<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609481
Report Date: 03/16/2022
Date Signed: 03/16/2022 10:57:46 AM

Document Has Been Signed on 03/16/2022 10:57 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:LWEAVER HOMES INCFACILITY NUMBER:
197609481
ADMINISTRATOR:WEAVER, LILLIANFACILITY TYPE:
735
ADDRESS:39801 171ST STREET EASTTELEPHONE:
(310) 922-0364
CITY:PALMDALESTATE: CAZIP CODE:
93591
CAPACITY: 4CENSUS: 2DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lillian WeaverTIME COMPLETED:
10:50 AM
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 visit to the facility and was greeted by Administrator, Lillian Weaver, at the front door. LPA observed the COVID signs and the Administrator was wearing a mask. LPA observed the sign in station and LPA's temperature was recorded. LPA observed the masks, sign in sheet, hand sanitizer, and thermometer .Administrator stated has two residents and stated one resident was participating in a work program.

LPA and Administrator began the tour at 10:05 am. LPA observed the living room/dining room combination. LPA observed the kitchen and observed an adequate supply of frozen and fresh food within the refrigerator. LPA observed a five day supply of fresh fruits and vegetables. All items in the refrigerator were covered. The pantry contained six day supply of canned vegetables. Administrator confirmed there are two resident rooms. LPA viewed a resident room which contained bed, linens, chest of drawers, lamp and lamp stand and a master bathroom. LPA observed the other resident bedroom; the resident was watching television. The room also contained all the necessary requirements.

LPA observed both bathrooms which contained wash your hands sign, hand soap, paper towels, and a trash can. LPA observed knives, resident medications and PPE supplies in the closet. LPA was escorted to the locked garage and observed additional PPE, washer/dryer, and washing detergent. LPA was escorted outside and observed the gate was not locked. The staff bedroom was also locked.

There are no deficiencies to report. Exit interviewed, appeal rights discussed, and a copy of the report was given to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1