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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609872
Report Date: 03/08/2023
Date Signed: 03/08/2023 11:13:57 AM


Document Has Been Signed on 03/08/2023 11:13 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:
03/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erwin EstrellaTIME COMPLETED:
11:15 AM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and was greeted by two caregivers. LPA observed both caregivers were wearing masks. LPA explained the purpose of the visit is to tour the facility and ensure there are no safety issues.

LPA conducted a tour of the facility with caregiver from 10:00 am until 10:15 am. LPA observed all cleaning supplies, medications, and knives were safely locked in the facility. The facility had a seven day supply of non perishable food and a two day supply of perishable food.

At 10:10 am, LPA and Caregiver walked into Resident Room One and LPA observed the door leading outside from Room One contained a portable door locking mechanism. The caregiver stated there is no resident living in the room and the lock mechanism is to ensure the door does not blow open when there is a windy day. LPA stated any door leading outside cannot contain the locking mechanism.

The Administrator arrived to the facility at 10:15 am.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is cited (refer to LIC 809-D). and a civil penalty issued (See LIC 421FC).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was given to the Administr
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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 03/08/2023 11:13 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: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2023
Section Cited

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87307 Personal Accomodations & Services (d)The following space and safety provisions shall apply to all facilities. (6) All outdoor & indoor passageways...shall be kept free of obstruction. This requirement was not met as evidenced by:
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LPA observed Caregiver removed the lock. LPA discussed with Caregivers and Administrator that the lock mechanism cannot be used on any exit door.
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Based on LPA's observation of the portable lock used in Room One to the door that leads out of the facility, staff did not comply with the section cited above which poses a potential health, safety & 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: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
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