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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609872
Report Date: 09/23/2022
Date Signed: 09/23/2022 10:18:06 AM


Document Has Been Signed on 09/23/2022 10:18 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ANAVERDES VILLAFACILITY NUMBER:
197609872
ADMINISTRATOR:ESTRELLA, ERWINFACILITY TYPE:
740
ADDRESS:37335 PAINTBRUSH DRTELEPHONE:
(661) 526-7000
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 4DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Erwin EstrellaTIME COMPLETED:
10:00 AM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and was greeted by caregiver. LPA stated the purpose of the visit was to conduct an annual inspection. LPA observed two caregivers were wearing masks. LPA's temperature was taken. LPA signed in at the sign in station and answered the COVID questions. Caregivers confirmed there are four residents

LPA conducted the tour with Administrator. LPA observed the kitchen/dining room/family room are combined. LPA observed comfortable seating was located in the family room and the dining room contained chairs and table. LPA observed the knives and medications are locked in a kitchen cabinet. The cleaning supplies were securely locked underneath the kitchen sink. LPA observed paper towels, trash can, and hand soap were located in the kitchen. LPA observed a 90-day supply of PPE in a kitchen cabinet. The facility also contained three-day supply of fresh vegetables and fruits, frozen meats, and a seven-day supply of canned goods, pasta, and snacks. LPA observed the facility was neat and clean. LPA observed two residents eating breakfast and a resident participating in a you tube exercise class.

LPA observed the residents rooms which all contained bed, linens, chest of drawers, night stand and lamp. The bathrooms contained wash your hands sign, hand soap, paper towels, and trash can. The backyard contained comfortable seating and the gate leading to the front yard was not locked. The hallway closet was locked and contained resident hygiene items. Another hallway closet contained clean linens.

LPA observed the staff room which was not locked. LPA was granted permission to enter the room and observed staff member's medication was not securely locked in the room. LPA stated staff room should be locked at all times. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights discussed, and a copy of the report was given to the Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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Document Has Been Signed on 09/23/2022 10:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANAVERDES VILLA
FACILITY NUMBER: 197609872

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful... accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Based on LPA's observation of the staff room, staff 's personal medication was not securely locked which poses a potential health safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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