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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609674
Report Date: 11/16/2022
Date Signed: 11/16/2022 04:43:42 PM


Document Has Been Signed on 11/16/2022 04:43 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:
11/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tracey TindleTIME COMPLETED:
01:30 PM
NARRATIVE
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LPA Spaeth arrived to the facility and was greeted by Administrator. LPA observed the COVID signs on the front door. LPA stated the purpose of the visit was to conduct a case management visit regarding incident report received by CCL. LPA observed two residents (R1 and R2) were participating in activities. LPA was advised R3 was away from the facility. LPA's temperature was recorded and LPA was requested to sign in at the sign in station.

LPA observed the facility was well stocked with a seven day supply of canned goods and a two day supply of fresh vegetables. The knives and medications were locked in a file cabinet in the dining room. LPA observed the three bathrooms contained hand soap, paper towels, and a trash can. LPA observed two residents' rooms which contained bed, linens, night stand, and lamp.

LPA observed two staff members were not wearing masks. Based upon LPA's observation, the following deficiency was cited. See attached 809-D for further details
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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 2


Document Has Been Signed on 11/16/2022 04:43 PM - It Cannot Be Edited

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: VERBENA CT
FACILITY NUMBER: 197609674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2022
Section Cited

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80078 Personal Rights (a)...each client shall have personal rights which include (2) to be accorded safe, healthful and comfortable accomodations...This requirement is not met as evidenced by:
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LPA observed two caregivers were not wearing a mask when LPA arrived to the facility. This poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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