197610027-5-21-2021-31-AS-MSPH-C38U9J-20210521152314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610027
Report Date: 05/21/2021
Date Signed: 05/21/2021 03:24:23 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:	(661) 940-7193
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	6	CENSUS: 3	DATE:	05/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Leandro Andrada and Mayba Andrada		TIME COMPLETED:	11:45 AM

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LPA Spaeth conducted an infection control visit with Administrator Leandro Andrada and Mayba Andrada.. Upon arriving at the front door at 10:20 am, LPA observed the COVID signs posted on the door. LPA was greeted by both Leandro and Mayba who were both wearing a mask. Mayba Andrada took LPA Spaeth’s temperature and instructed LPA to sign in. LPA Spaeth observed wear a mask sign at the sign in station. LPA signed in and answered questions regarding COVID 19. LPA Spaeth was then led to the dining room and living area to begin the tour of the facility.

LPA Spaeth observed an adequate supply of food in the refrigerator, freezer, and pantry section of the kitchen. LPA saw there was hand soap, paper towel, and wash your hands sign in the kitchen. Mayba Andrada opened the locked cabinet which contained the knives and unlocked a cabinet which contained residents’ medications. The cabinet underneath the sink which was locked and contained cleaning supplies.

LPA Spaeth was escorted down the hall and observed Room1, which currently does not have any residents within the room. Across the hall was the bathroom and LPA observed wash your hands sign, hand soap, paper towels and trash can. Administrator unlocked the laundry room and LPA observed the washing machine and dryer. Administrator then unlocked the garage door and was led out to the garage where LPA observed another refrigerator with food and other stored items.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

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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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: 05/21/2021

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LPA Spaeth observed the door to Room 2 was closed. Administrator stated resident was sleeping. Upon passing Room 3, LPA observed resident was sleeping in room. LPA Spaeth entered the master bedroom along with the Administrator and observed one resident’s bed in the middle of the room. LPA Spaeth observed the master bedroom contained wash your hands sign, hand soap, paper towels, and a trash can.

Administrator then unlocked a storage closet and LPA observed hygiene items, N95 masks, gowns, gloves, hand sanitizer, and face shields. LPA Spaeth observed a 90-day supply of all PPE available for use. Upon returning to the living area, LPA Spaeth was escorted to the sliding glass door. LPA Spaeth observed one resident was in the living room and working on a crossword puzzle. LPA Spaeth observed patio furniture available outside for residents and visitors.

LPA Spaeth confirmed the facility is cleaned and sanitized once per day and LPA observed the facility was thoroughly clean when conducting the tour. Administrator confirmed there is an on-call staff member who has been vaccinated and been thoroughly trained regarding COVID-19 protocol.

The tour concluded at 11:45 am. Exit interviewed was conducted and LPA Spaeth stated will send report to Administrator via email. LPA Spaeth instructed administrator to sign and send to LPA via email.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC809 (FAS) - (06/04)

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