197610095-10-30-2023-31-AS-ERIS-CX4QDK-20231030120452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610095
Report Date: 10/30/2023
Date Signed: 10/30/2023 12:05:12 PM

Document Has Been Signed on 10/30/2023 12:05 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VALLEY HEIGHTS RESIDENTIAL CARE		FACILITY NUMBER:	197610095
ADMINISTRATOR:	UMEH, VIVIAN I.		FACILITY TYPE:	740
ADDRESS:	2647 W AVENUE K4		TELEPHONE:	(661) 802-7771
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 0	DATE:	10/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Vivian Umeh		TIME COMPLETED:	12:15 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	On 10/30/23 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced annual inspection at the facility mentioned above. LPA met with Administrator, Vivian Umeh. Facility currently has no residents in care. LPA explained the purpose of the visit. This facility is a residential care facility for the elderly. Facility is licensed for six (6) residents for four (4) ambulatory and two (2) non-ambulatory of which one (1) may be bedridden. LPA and Administrator discussed items on the infection control domain and updated protocols. Administrator stated she will notify LPA when facility has staff and residents. According to Administrator infection control plan was submitted for approval last year when requested by LPA Ruiz. The smoke detectors are battery operated and interconnected. Administrator tested smoke detectors at 11:30 a.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen and fully charged. LPA observed three (3) carbon monoxide detectors and were observed to be functioning properly. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives will be stored in a locked cabinet in the kitchen. Bedrooms: There are three (3) bedrooms designated for residents' use. Bedroom are shared and were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. (Continued to LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY HEIGHTS RESIDENTIAL CARE	FACILITY NUMBER: 197610095
	VISIT DATE: 10/30/2023

NARRATIVE

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(Continued from LIC809)
Common Areas: These included the living area and dining area. The common areas were properly furnished.

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards and has a outdoor furniture with an umbrella for shade. LPA observed a shed used for storage. The laundry area is located in the garage detergents and cleaning chemicals are kept locked.

Resident Files/Staff Files/Medication Records: Records will be stored in the office locked.

Medications: Medications will be kept locked in a kitchen cabinet inaccessible to residents in care. LPA observed a complete first aid kit in the kitchen.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during todays visit. Exit Interview Conducted. A copy of the report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC809 (FAS) - (06/04)

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