197609715-12-9-2024-31-AS-ERIS-DBSR8L-20241209114807

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609715
Report Date: 12/09/2024
Date Signed: 12/09/2024 11:48:15 AM

Document Has Been Signed on 12/09/2024 11:48 AM - 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/ DIRECTOR:	ASSEFA, YAYINEABEBA		FACILITY TYPE:	740
ADDRESS:	44812 RUTHRON ST		TELEPHONE:	(703) 589-4408
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	12/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Yayineabeba Assefa / Lena Johnson		TIME VISIT/ INSPECTION COMPLETED:	12:02 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 12/09/2024 at 9:30 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. S1 requested LPA wash hands before continuing into the home. S1 contacted the administrator. House manager Lena Johnson met LPA at approximately 9:43 a.m. LPA explained the reason for the visit. The facility is licensed for three (3) ambulatory, three (3) non ambulatory of which one (1) may be bedridden with a total capacity of six (6) residents. Facility has a Hospice wavier for two (2). The inspection tool was used to complete the visit. A physical tour was conducted at approximately 9:45 a.m. along with the house manager 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 12/05/2024, fully charged. A second was by the kitchen with same purchase date. Common Areas: These include the dining area, 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 properly secured with a 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 supply of 7-day non-perishable foods and 2-day perishable foods; properly stored. Bedrooms: There are four (4) bedrooms designated for resident use. One (1) out of four (4) bedrooms is a shared. Continued to LIC809-C)

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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
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: 12/09/2024

NARRATIVE

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(Continued from LIC809) All resident rooms are furnished with required lighting, dresser, chair, bed, linens, and closets for storage. LPA observed a hallway closet with extra linens.

Bathrooms: There are three (3) bathrooms designated for resident use. One (1) bathroom is located in the shared bedroom for private use. All bathrooms were clean, had grab bars, had non-slip mats, and trash bins with lids. LPA observed a sufficient supply of hand soup, toilet paper, and paper towels. At approximately 9:50 a.m. hot water temperature in one (1) bathroom was measured at 116.5°F, with regulation.

LPA observed dual smoke and carbon monoxide alarms through out the facility, they are interconnected and hard wired. At approximately 9:58 a.m. the house manager tested the smoke alarms and they were observed functioning properly.

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 is used for facility storage.

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.

Resident and Staff Files: At approximately 10:20 a.m. LPA conducted a file review of two (2) out of two (2) resident's files. LPA reviewed resident records to insure compliance of licensing forms. Administrator, Yayineabeba Assefa arrived at 10:24 a.m., LPA also conducted a staff file review at 10:48 a.m., of three (3) staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: 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 11:00 a.m. LPA and administrator reviewed centrally stored medication records and medication. LPA reviewed facility's fire drills, disaster training and discussed facility's liability insurance and infection control plan.

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: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

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