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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609715
Report Date: 12/07/2022
Date Signed: 12/07/2022 12:18:38 PM

Document Has Been Signed on 12/07/2022 12:18 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
N LA & CEN COA AC/SC, 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: 2DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Yayineabeba AssefaTIME COMPLETED:
12:30 PM
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On 12/07/2022 at 11:06 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required Annual/ Infection Control inspection at the facility mentioned above. LPA was greeted by Administrator Yayineabeba Assefa who granted access. Administrator Yayineabeba took LPA's temperature. LPA explained the reason for the visit. LPA reviewed the Mitigation Plan approved 04/10/2021. The inspection tool was used to complete the visit.

A physical tour was conducted at 11:07 a.m. and LPA observed the following:

Infection control: Proper infection control sign was observed on the outside front door of the facility. Upon entrance, LPA observed, proper infection control signs, hand sanitizer and masks were available. Administrator requested LPA to wash their hands or use hand sanitizer upon entrance. Administrator states the facility has enough PPE for 30 days. The fire extinguisher was observed by the front door and with a purchased date of on 11/09/2022.

Common Areas: These include the dining areas, and two (2) living rooms. All common areas were observed well lit, clean and clear of clutter. Furniture appeared clean and in good repair. There is a fire place in one (1) of the living rooms but is not in use. LPA observed the thermostat at a comfortable temperature of 74°F.

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Knives are kept locked in a kitchen drawer inaccessible to residents. LPA observed there to be sufficient stock of 7-day non-perishable foods and 2-day perishable foods. A 2nd fire extinguisher was observed by the back patio sliding door and with a purchased date of on 11/09/2022.

Bedrooms: There are four (4) bedrooms designated for resident use. Two (2) out of the four (4) rooms are currently vacant. One (1) out of four (4) is a shared bedroom with only one occupant. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HEAVENLY HOME CARE
FACILITY NUMBER: 197609715
VISIT DATE: 12/07/2022
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Bathrooms: There are two (3) bathrooms designated for resident use. One (1) bathroom is located in the shared bedroom for private use. The other two (2) bathrooms are accessible to all the residents. All bathrooms were well lit, clean, had grab bars, had hand washing signs and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels. At approximately 11:20 a.m. water temperature in the one (1) out of the three (3) bathrooms was measured at 113.4°F.

Laundry Room/Garage: Laundry room is kept locked. LPA observed a washer and dryer that appeared operative. Detergents are kept in a cabinet above the washer and dryer. Through the laundry room is the door to the garage. The garage was observed to store the cleaning supplies, PPE and extra water.

Medications/ Resident file: LPA observed, resident medications and resident files locked in a closet inaccessible to residents.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gate on side of the house was closed but unlocked. There is appropriate outdoor seating for residents and a large umbrella to provide shade for residents.

LPA observed dual smoke and carbon monoxide alarms through out the facility, they are interconnected and hard wired. At 11:16 a.m. all smoke alarms were tested and functioned properly.



No deficiencies were observed during todays visit and the facility is currently following their infection control plan.

Exit interview conducted and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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