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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610057
Report Date:
09/29/2021
Date Signed:
09/29/2021 04:09:02 PM
Document Has Been Signed on
09/29/2021 04:09 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
CCLD Regional Office
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
MAHONIA AVE
FACILITY NUMBER:
197610057
ADMINISTRATOR:
TINDLE, TRACEY
FACILITY TYPE:
735
ADDRESS:
37206 MAHONIA AVE
TELEPHONE:
(661) 305-4744
CITY:
PALMDALE
STATE:
CA
ZIP CODE:
93552
CAPACITY:
6
CENSUS:
0
DATE:
09/29/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:15 AM
MET WITH:
Tracey Tindle
TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an announced annual visit to the facility today. The facility does not have any clients and is not vendor by North Los Angeles Regional Center. They have not had any clients at all since they have been licensed.
The LPA was greeted by Tracey Tindle the Administrator/Licensee. LPA was screened for COVID and temperature was taken. The home is a one story facility with 4 bedrooms. It is currently at the capacity of 6 but administrator would like to drop the capacity to 4 prior to her getting vendor. She will also change the use of one of the rooms to a live in staff quarters. She will submit a new LIC200 along with facility sketch to LPA by email.
The facility mitigation plan has been approved and a copy is at the facility. Upon entry to the facility the COVID 19 awareness signs are up and posted throughout the facility. There is a visitation plan in place to accommodate residents outside the facility. All 4 bedrooms are set up with linens and extra linens and hygiene products. The facility smoke detector is combined with the carbon monoxide detector and there is one fire extinguisher in the kitchen area. The living room area has a file cabinet for all client files and confidential files. There is a locked cabinet area that will hold all medications and has the complete first aid kit. The kitchen has a menu posted and can goods are available at this time.
There are no health or safety issues. No citations issued. Exit interview conducted. Copy of report to be emailed to administrator.
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Angelica Arambulo
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/29/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/29/2021
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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