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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609715
Report Date: 11/08/2021
Date Signed: 11/08/2021 01:39:30 PM

Document Has Been Signed on 11/08/2021 01:39 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:HEAVENLY HOME CAREFACILITY NUMBER:
197609715
ADMINISTRATOR:ASSEFA, YAYINEABEBAFACILITY TYPE:
740
ADDRESS:44812 RUTHRON STTELEPHONE:
(703) 589-4408
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 3DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Yayineabeba AssefaTIME COMPLETED:
01:50 PM
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At 12:39 am, Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff who granted access to the facility and later met with Administrator Yayineabeba Assefa. This is a single-story residential care facility for the elderly with five (5) bedrooms and three (3) bathrooms. A physical tour was conducted at 12:50 pm and observed the following:

Infection control: Proper signage was observed outside the facility and near the main entrance of the facility. Upon entrance, staff took LPA's temperature, and LPA prompted staff to have LPA sign-in the visitor’s log. No infection control questions were asked, hand sanitizer and masks were available. LPA reminded Administrator and staff to follow their mitigation plan for infection control protocol. Trash cans were observed to have closed tight fitting lids. Sufficient PPE supplies were observed. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored in designated storage areas throughout the facility and are kept locked. Smoke detectors/carbon monoxide are dual and hardwired throughout the facility. At 1:00 pm they were tested and appear functional. Common Areas: These include the dining areas, living rooms. All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 71.0 F. Garage/Laundry: There is a laundry room that leads to the attached garage. Extra linens and towels were observed. Both areas are kept locked and inaccessible to residents.Bathrooms: The hot water temperature measured at 113.1 F. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. No deficiencies cited. An exit interview was conducted. A copy of this report was provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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