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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609821
Report Date: 10/28/2024
Date Signed: 10/28/2024 02:49:52 PM

Document Has Been Signed on 10/28/2024 02:49 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:A HOME FOR YOUFACILITY NUMBER:
197609821
ADMINISTRATOR/
DIRECTOR:		NEPOMUCENO, MERLITAFACILITY TYPE:
740
ADDRESS:43845 GENERATION AVETELEPHONE:
(818) 357-8667
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Merlita NepomucenoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 10/28/2024 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator Merlita Nepomuceno. LPA Rios explained the purpose of the visit to the administrator. Facility has an approved fire clearance for five (5) non ambulatory residents and one (1) bedridden resident for a total capacity of six (6). Facility has a hospice waiver for six (6).

At 12:26 p.m. LPA and administrator Merlita conducted a physical plant tour and the following was observed:

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Cleaning products were stored in a locked cabinet under the kitchen sink. Medication stored in a locked kitchen cabinet.

Bedrooms: There are four (4) bedrooms designated for residents' use. One (1) room is shared. Resident bedrooms were furnished with beds, night stand, chairs, dressers, bedding and linens. The bedrooms have sufficient lighting and storage.

Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 1:47 p.m. and read 113.5 degrees Fahrenheit, within regulation.

Common Areas: These included the living area and dining area. The common areas were clean and properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.
(Continued to LIC809-C)
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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: A HOME FOR YOU
FACILITY NUMBER: 197609821
VISIT DATE: 10/28/2024
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The smoke alarms are battery operated and interconnected. LPA observed a carbon monoxide detector by kitchen. A caregiver tested smoke and carbon detectors at 1:30 p.m. and they were observed to be functioning properly. The fire extinguisher is located in the kitchen with purchase date 05/24/2024.

Surrounding Grounds: The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage.

Laundry/Garage: A staff room that is maintained locked leads to the laundry room which leads to the attached garage. Detergents and cleaning products are kept in the laundry room locked in a cabinet.

Resident Files/Medications: At 12:36 p.m. LPA conducted a file review of four (4) resident records to insure compliance of licensing forms. LPA and administrator reviewed centrally stored medication and medication records for proper documentation. Facility also keeps a Medication Administration Record (MAR).

Staff Files: At 1:50 p.m. LPA also conducted a file review of four (4) staff records to insure forms and training are up to date and compliance with licensing forms.


Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A copy of the report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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