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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609674
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:20:53 PM

Document Has Been Signed on 02/04/2022 03:20 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:VERBENA CTFACILITY NUMBER:
197609674
ADMINISTRATOR:TINDLE, TRACEYFACILITY TYPE:
735
ADDRESS:37318 VERBENA CTTELEPHONE:
(661) 305-4744
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 3DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tracey TindleTIME COMPLETED:
02:30 PM
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LPA Spaeth arrived to the facility and observed the COVID signs on the front door. LPA was greeted by caregiver, Breanna Hall. LPA observed two other caregivers, Todd Smith and Robin Jackson who were wearing masks and assisting residents. LPA's temperature was taken and LPA observed the sign in station which contained thermometer, sign in sheet and hand sanitizer. LPA was also greeted by a resident who was completing an activity with a caregiver. Caregivers confirmed there are three residents.

At 1:30 pm, Administrator Tracey Tindle arrived and conducted a tour of the facility with LPA Spaeth. LPA observed the dining room with comfortable seating, dining room table and a sectional couch. LPA was then escorted to the family room/kitchen area combination. The family room contained a sectional along with a television. LPA then observed the kitchen at 1:45 pm. LPA observed an adequate supply of fresh fruits, vegetables, drinks, and eggs. The freezer was well stocked with frozen meats. Within the kitchen sink area, LPA observed wash your hands sign, hand soap, paper towels, and a trash can. The pantry was stocked and well organized with canned goods. The knives and medications were locked in the dining room area in a locked file cabinet.

LPA observed the three resident rooms which contained bed, linens, night stand, night lamp and ample storage space in each room. The rooms were neat and clean. LPA observed the three bathrooms which contained wash your hands sign, hand soap, paper towels, and a trash can. The hallway closet contained clean linens. The laundry room contained the wash/dryer, and personal hygiene items. The garage contained a 90 day supply of PPE and an additional freezer was full of food.

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

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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