197610027-6-1-2020-31-AS-MSPH-BQ6QYK-20200601123516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610027
Report Date: 06/01/2020
Date Signed: 06/01/2020 12:36:22 PM

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:	ALLESSANDRA HOME CARE		FACILITY NUMBER:	197610027
ADMINISTRATOR:	ANDRADA, LEANDRO		FACILITY TYPE:	740
ADDRESS:	2822 ALLESSANDRA COURT		TELEPHONE:	(818) 294-3444
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	6	CENSUS: 6	DATE:	06/01/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Leandro Andrada		TIME COMPLETED:	12:34 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Melissa Spaeth conducted Pre-Licensing Visit to the facility and met with the Applicant/Licensee representative Leandro Andrada and Mayba Andrada. LPA explained to the applicant that this visit was to conduct the Comp III presentation with Administrator, to inspect physical plant, and to assure that the facility is meeting Title 22 General and Regulations. The tour of the facility was conducted with the assistance of the applicant. The physical plant is a single family dwelling. The applicant is planning to serve six residents, five non-ambulatory and one bedridden resident. The facility consists of one living room, family room, four resident bedrooms, one staff room, and kitchen. The living room contained comfortable furniture with a designated sign-in area which included a sign-in sheet for visitors, and COVID-19 signs posted along with hand sanitizer. Also, LPA observed Ombudsmen sign, resident rights, and Let Us Know postings within the living room area. While walking to the kitchen, LPA observed a staff room (Room #5) to the left which is locked and also contains a bed for staff to sleep. LPA walked into a large room which is the kitchen, family room, and dining room. LPA observed an adequate supply of fresh vegetables, fresh fruits, frozen meats, eggs, and drinks within the refrigerator. LPA observed a locked cabinet designated for medications. A locked kitchen drawer contained knives. LPA observed a locked cabinet under the sink which contained dish detergent. LPA was directed to a pantry within the dining area which contained an adequate supply of canned goods, pasta, and other dried goods. LPA and the administrator toured the backyard. LPA walked through sliding glass door to the outside area which consisted of a covered awning with comfortable seating for residents. LPA observed one exit out of the backyard leading to the front yard. The gate leading of the backyard was not locked.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: ALLESSANDRA HOME CARE	FACILITY NUMBER: 197610027
	VISIT DATE: 06/01/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed all rooms contained a bed, lamp, lamp stand, and adequate storage space for each resident, comfortable bed with sheets and a pillow. LPA observed Bedroom #4 contained two beds and a bathroom for non-ambulatory residents. Bedroom #3 is designated for one bedridden resident. This room contained an exit door. Bedroom #2 is designated for one non-ambulatory resident and Bedroom #1 for two non-ambulatory residents.

LPA observed a locked door which lead to the laundry room. LPA observed laundry detergent, washer, dryer, and a locked small refrigerator for medications. LPA also observed a locked door that led to the garage. Within the garage, LPA observed garden tools stored in a plastic bin.

LPA observed two bathrooms within the facility. Both bathrooms contained COVID-19 wash your hands postings, soap, paper towels, non slip mats in the bathrooms, covered garbage cans, and necessary grab bars. LPA Spaeth tested water temperature which was 113.4 F which was tested at 10:30 am.

LPA Spaeth observed three doors that lead out of the facility. All doors contained proper alarms for dementia residents. Administrator tested smoke detectors and carbon monoxide detectors for LPA and LPA noted all were properly working. LPA observed in the hallway area storage for all linens. Administrator had an ample supply of towels, sheets, pillows, etc. LPA observed puzzles and other games available for residents. LPA observed the fire estinguisher in the kitchen. Administrator also presented monthly meal menu and activities scheduled for the residents. The chemicals and cleaning supplies were locked in the garage. LPA also noted locked cabinet in the kitchen for medications.

There were no deficiencies documented. Report was read; exit interview completed

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2