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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610057
Report Date: 09/29/2022
Date Signed: 09/29/2022 10:27:27 AM

Document Has Been Signed on 09/29/2022 10:27 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:MAHONIA AVEFACILITY NUMBER:
197610057
ADMINISTRATOR:TINDLE, TRACEYFACILITY TYPE:
735
ADDRESS:37206 MAHONIA AVETELEPHONE:
(661) 305-4744
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 0DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Tracey Tindle, Administrator TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Angela Panushkina conducted an announced annual visit to the facility today. LPA met with the Administrator and explained the reason for the visit.

Upon arrival LPA was screened for COVID and temperature was taken. COVID awareness signs are up and posted throughout the facility.

The facility have not had any clients at all since they have been licensed. Request for proposal through a Regional Center had been completed and now the Administrator has to develop a program. LPA was informed that one the vendorization process is complete they'll be able to accept clients. It is currently at the capacity of 6, but Administrator will 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.

There is a visitation plan in place to accommodate clients outside the facility. The home is a one story facility with 4 bedrooms and 2 bathrooms. 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. At 9:40am, smoke detectors were tested and observed to be operational. Facility has two fire extinguishers, one in the kitchen area and one in the laundry area. Both fire extinguishers were last serviced on 08/25/22. The living room area has a file cabinet for all client files and confidential files. There is a locked cabinet area by the kitchen 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. Report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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