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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609674
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:03:19 PM

Document Has Been Signed on 02/19/2025 04:03 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/
DIRECTOR:		TINDLE, TRACEYFACILITY TYPE:
735
ADDRESS:37318 VERBENA CTTELEPHONE:
(661) 305-4744
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Tracey TindleTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by two staff members. LPA called the Administrator, Tracey Tindle who stated will be arriving to the facility. LPA stated the purpose of the visit was to conduct an annual inspection. The staff confirmed there are four residents living in the facility. The facility is licensed for four (4) ambulatory clients.

LPA Spaeth and the caregiver toured the facility at 10:20 am until 10:50 am.

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 dining room area.

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.

Continued 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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: 02/19/2025
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Laundry Area – The laundry room was locked and contained the washer/dryer, hygiene items, and the laundry detergent. The door leading from the laundry room to the garage was locked.

Bathroom - The bathrooms are supplied with hand soap, paper towels and a trash can. The water was tested at 12:28 pm and was 118.0 degrees F.

Garage – LPA observed an additional freezer was located in the garage. The cleaning solutions were locked in the garage

Client Rooms: LPA Spaeth observed the bedrooms contained bed, linens, night stand, night lamp and chest of drawers.

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.

Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 10:30 am and were operable.

LPA reviewed resident files at 11:00 am until 11:35 am. LPA reviewed staff records at 11:45 am until 12:15 pm. LPA reviewed clients' medications at 12:45 pm until 12:55 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: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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