197609715-3-4-2024-31-AS-ERIS-D32S7B-20240304123716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609715
Report Date: 03/04/2024
Date Signed: 03/04/2024 12:37:35 PM

Document Has Been Signed on 03/04/2024 12:37 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 CARE		FACILITY NUMBER:	197609715
ADMINISTRATOR:	ASSEFA, YAYINEABEBA		FACILITY TYPE:	740
ADDRESS:	44812 RUTHRON ST		TELEPHONE:	(703) 589-4408
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 2	DATE:	03/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Yayineabeba Assefa		TIME COMPLETED:	12:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 03/04/2024 at 9:20 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required Annual Inspection at the facility mentioned above. LPA was greeted by staff #1 (S1) who granted access. Administrator Yayineabeba Assefa met LPA shortly after. LPA explained the reason for the visit. The facility is licensed for 3 non ambulatory and 1 bedridden with a total capacity of six (6) residents. Facility has a Hospice wavier for 2. The inspection tool was used to complete the visit.

A physical tour was conducted at approximately 11:40 a.m. along with the administrator and LPA observed the following:

Entrance: LPA observed proper postings along a wall by the first living room and dining table. LPA observed hand sanitizer and masks were available. The fire extinguisher was observed by the front door with a purchased date of on 11/15/2023 fully charged.

Common Areas: These include the dining areas, and 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 not in use properly secured with a glass screen.

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 with a purchased date of on 11/15/2023.

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, linens, and closets for storage. LPA observed a hallway closet with extra linens. (Continued to LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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 3

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: 03/04/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed dual smoke and carbon monoxide alarms through out the facility, they are interconnected and hard wired. At approximately 10:00 a.m. the administrator tested the smoke alarms were observed functioning properly.

Bathrooms: There are three (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, toilet paper, and paper towels. At approximately 10:03 a.m. hot water temperature in the one (1) out of the three (3) bathrooms was measured at 116.5°F.

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

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. There is appropriate outdoor seating for residents and a large umbrella to provide shade.

Medications/ Resident file: At approximately 10:10 a.m. LPA observed, resident medications and resident files locked in a closet inaccessible to residents. Facility keeps a medical administration record (MAR) with updated doctor orders on file. LPA observed a first aid kit in the same closet. At approximately 10:40 a.m. LPA conducted a file review of two (2) out of two (2) residents. LPA reviewed resident records to insure compliance of licensing forms.

Staff Files: At approximately 11:00 a.m. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

No deficiencies were observed during todays visit. Exit interview conducted and a copy of this report issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3