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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609821
Report Date: 10/08/2021
Date Signed: 10/08/2021 11:23:47 AM

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:A HOME FOR YOUFACILITY NUMBER:
197609821
ADMINISTRATOR:NEPOMUCENO, MERLITAFACILITY TYPE:
740
ADDRESS:43845 GENERATION AVETELEPHONE:
(818) 357-8667
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee - Jonathan NepomucenoTIME COMPLETED:
11:40 AM
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At 10:00 am, Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff (S1) who granted access to the home and later met with licensee Jonathan Nepomuceno. This is a 5-bedroom, 2-bathroom single story residential care facility for the elderly. A physical tour was conducted at 10:20 am and observed the following: Infection control: Proper signage was observed outside the home and along the main entrance of the facility. Upon entrance, staff took LPA's temperature and was asked to sign-in the visitor’s log but was not asked any infection control questions. Hand sanitizer was available, and all trash cans were observed to have closed tight fitting lids. Sufficient PPE supplies were observed. LPA reminded licensee to review their mitigation plan with all staff to ensure all visitors are thoroughly screened upon entry. 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. Garbage cans have tight fitting covers in the kitchen. Sharps, cleaning supplies and medications are centrally stored in a locked cabinet in the kitchen. Smoke detectors/carbon monoxide were located throughout the facility. At 10:45 am, they were tested and are functional. Facility maintains a comfortable temperature of 76.0 F. Resident rooms: There are four (4) bedrooms designated for resident use, one (1) bedroom is designated for live-in staff. All bedrooms are properly furnished, cleaned and have appropriate bedding and linens. Bathrooms: The hot water temperature measured at 108.8 F. Towels and washcloths are not shared. The garage is attached to the home and is used for storage, and a laundry area. Extra towels and linens were readily available. 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. Exit interview conducted.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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