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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610126
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:54:58 PM

Document Has Been Signed on 08/22/2024 03:54 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAUREL HOMEFACILITY NUMBER:
197610126
ADMINISTRATOR/
DIRECTOR:		ALEX ESPINOZAFACILITY TYPE:
737
ADDRESS:41447 W 25TH STREETTELEPHONE:
(661) 947-9612
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:ALEX ESPINOZATIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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LPA Spaeth conducted an unannounced visit and was greeted by the Administrator, Alex Espinoza. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are four ambulatory residents living at the facility.

LPA conducted a tour of the facility at 11:10 am until 11:40 am with the Administrator and LPA observed the facility was neat and clean.

Common Areas – LPA observed the living room contained comfortable seating along with a television. The dining room area contained a dining room table and chairs. At 11:20 am, LPA observed the medication cart was locked and was located in the dining room area. The medication cart contained the client's medications and the first aid kit.

Living Room Closet – LPA observed the cleaning solutions, personal hygiene items and additional supplies were locked within the closet.

Kitchen – LPA observed the kitchen knives were securely locked. The facility contained a two-day supply of perishable food and a seven-day supply of non-perishable food items. LPA tested the water temperature at 11:09 am, which was 109 degrees F. A fire extinguisher is also located in the kitchen.

Clients' Bedrooms - There are four bedrooms in the home which are furnished with a bed, linens, night stand, chest of drawers and a closet.

Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAUREL HOME
FACILITY NUMBER: 197610126
VISIT DATE: 08/22/2024
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Washer/Dryer - The washer and dryer are located within the facility. The laundry detergent was locked in a cabinet above the washer and dryer.

Backyard - LPA observed the backyard which has a shaded area with seating. The gate leading from the back yard to the front yard was not locked.

Garage - LPA observed the garage is used as the Administrator's office. The resident and staff records were securely locked in the garage. LPA Spaeth observed the emergency food and water are stored within the facility.

LPA reviewed the residents' files at 12:00 pm until 1:00 pm and reviewed the staff files at 1:00 pm until 1:30 pm. There are no issues to report.

LPA reviewed the residents’ medication at 1:30 pm until 1:40 pm.

There are no deficiencies to report. Exit interview was conducted and a copy of the signed report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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