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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610126
Report Date: 08/11/2021
Date Signed: 08/11/2021 12:05:11 PM

Document Has Been Signed on 08/11/2021 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
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:
(909) 305-9663
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 0DATE:
08/11/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Alexandra StixTIME COMPLETED:
12:27 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct a pre-licensing visit. LPA was greeted by the facility administrator, Alexandra Stix, Serena Rojas Executive Director, and Robert Subia, Program Manager who were all present during the visit. This is an Enhanced Behavioral Home.
LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. First-aid kit is complete; facility has adequate linen, perishable and nonperishable food supplies. Hot water measured at 116.7 degrees Fahrenheit. There is no swimming pool or other body of water. The backyard is fenced and gated with self-latching mechanisms. There is patio area in the backyard with table and chairs for resident use. All chemicals and sharps are stored in a locked cabinet. Medications are stored in a locked cabinet across from the kitchen. Facility has 4 bedrooms and 2 bathrooms. Fire Clearance is approved for 4 non ambulatory residents. There are no shared rooms and 4 single rooms. The washer and dryer are located in a hallway next to the kitchen.

Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Unit (CAU). You will be notified by the CAU Analyst when your license has been approved.
You are not allowed to begin operating until you have been notified that your license has been approved by the CAU Analyst. Failure to comply could affect approval of your license.
Exit interview held and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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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