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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610126
Report Date: 07/29/2022
Date Signed: 07/29/2022 11:21:34 AM

Document Has Been Signed on 07/29/2022 11:21 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:LAUREL HOMEFACILITY NUMBER:
197610126
ADMINISTRATOR:STIX, ALEXANDRAFACILITY TYPE:
737
ADDRESS:41447 W 25TH STREETTELEPHONE:
(661) 947-9612
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 3DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Yolanda PickensTIME COMPLETED:
11:15 AM
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LPA Spaeth conducted an unannounced visit and was greeted by Administrator. LPA observed administrator and all staff were wearing masks. LPA's temperature was taken and LPA was asked to complete the sign in process at the front door. LPA observed masks, sign in sheet, hand sanitizer and COVID sign in sheet for all guests. Administrator confirmed there are three residents.

LPA and Administrator began the tour at 9:35 am. LPA observed the kitchen area. At 9:40 am, LPA observed the knives were securely locked in a cabinet. The med cart is located in the dining room and was locked. LPA observed the med cart contained the first aid kit and thermometer. The refrigerator contained a five day supply of fresh vegetables and fruit. The freezer section contained frozen meats. The pantry contained a seven-day supply of canned goods and pasta items.

There are four bedrooms in the home which are furnished with a bed, linens, night stand, chest of drawers and a closet. There are two bathrooms in the facility which contained the required hand soap, wash your hands sign, paper towels, and a trash can. The facility was neat and clean.

LPA observed the backyard which has a shaded area with seating. Two residents and three staff members were enjoying the sunshine. The laundry area contained washer and dryer. The laundry detergent was locked in a cabinet above the washer and dryer. All hygiene items are located in a hallway closet.

LPA observed the garage which is used as the Administrator's office. LPA observed there is an adequate supply of PPE items.

There are no deficiencies to report. Exit interview was conducted, appeal rights discussed, and a copy of the signed report was given to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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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