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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609787
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:49:12 PM

Document Has Been Signed on 03/09/2022 03:49 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:SANTA CLARITA VALLEY SENIOR CENTERFACILITY NUMBER:
197609787
ADMINISTRATOR:MACDONALD, KEVINFACILITY TYPE:
775
ADDRESS:27180 GOLDEN VALLEY ROADTELEPHONE:
(661) 259-9444
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY: 35CENSUS: DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kevin MacDonaldTIME COMPLETED:
04:01 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Kevin MacDonald for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:45pm and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs are posted outside. Hand washing, coughing etiquette, physical distancing and other necessary signs are posted in the bathroom and throughout the facility. The facility has enough PPE supplies. The facility is fire cleared for eight (08) non-ambulatory and twenty-seven (27) ambulatory clients. The facility does not have a swimming pool/body of water. Cleaning agents and other toxins are locked away. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to clients. Common area furniture was also checked. The common area is neat and clean. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located near the kitchen area, observed to be full and last inspected on 10/24/2021. The facility has enough hygiene products available to the clients. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 117.2°F. Towels are not shared. LPA observed first aid kit to be locked and inaccessible to clients.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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