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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609674
Report Date: 02/09/2024
Date Signed: 02/09/2024 04:22:14 PM

Document Has Been Signed on 02/09/2024 04:22 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
WOODLAND HILLS S.ASC, 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: 4DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tracey TindleTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are four residents living in the facility. The facility is licensed for six (6) ambulatory clients.

LPA Spaeth and the caregiver toured the facility at 12:45 until 1:15 pm.

Common Areas – The living room and dining room are combined. The living room was furnished with comfortable seating. The dining room contained dining room table and chairs. The family room contained a television and comfortable seating.

Medications: LPA observed the resident medications, first aid kit, and knives were safely locked in a filing cabinet in the living room.

Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher was located near the kitchen and was operable.

Hallway- The linens were located in a hallway cabinet.

Laundry Area – The laundry room was locked and contained the washer/dryer and the laundry detergent. The door leading from the laundry room to the garage was locked.

Garage – LPA observed an additional freezer was located in the garage.

Bathrooms: There are two (2) client bathrooms and one staff bathroom. All bathrooms were well lit, clean, contained hand soap, paper towels and trash bins with lids. The water temperature was tested at 12:55 pm and was 119.0 degrees F.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VERBENA CT
FACILITY NUMBER: 197609674
VISIT DATE: 02/09/2024
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Client Rooms: Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard.

Bedrooms: LPA Spaeth observed each room contained bed, linens, chest of drawers, chair and closet. The rooms were neat and clean.



Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 1:00 pm and were operable.

LPA reviewed resident files and medications at 1:30 pm until 2:00 pm. LPA reviewed staff records at 2;00 pm until 2:40 pm.

There are no deficiencies to report at this time.



Exit interview conducted and a copy of this report issued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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