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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610126
Report Date: 08/22/2023
Date Signed: 08/31/2023 07:46:55 AM

Document Has Been Signed on 08/31/2023 07:46 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAUREL HOMEFACILITY NUMBER:
197610126
ADMINISTRATOR:YOLANDA PICKENSFACILITY TYPE:
737
ADDRESS:41447 W 25TH STREETTELEPHONE:
(661) 947-9612
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 3DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Alex Espinoza and Yolanda PickensTIME COMPLETED:
03:30 PM
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LPA Spaeth conducted an unannounced visit and was greeted by the back-up Administrator. LPA stated the purpose of the facility was to conduct an annual inspection. Staff confirmed there are three ambulatory residents living at the facility. The Administrator arrived at the facility at 10:15 am.

LPA reviewed client records at 9:15 am until 10:00 am. LPA reviewed staff records at 10:00 am until 10:45 am. The residents’ P&I funds were reviewed at 10:45 am until 11:00 am with the Administrator. LPA reviewed the residents’ meidcation at 11:00 am until 11:10 am. LPA conducted a tour of the facility at 11:10 am until 11:40 am with the back-up Administrator.

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 11:05 am, LPA observed the med cart was located in the dining room area and was locked.

Facility Closets – LPA observed the first aid kit, cleaning solutions, and washing detergent were located in a locked closet. The hygiene items were also securely locked in a closet.

Kitchen – LPA observed the kitchen was neat and clean and observed the 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 11:20 am, which was 105 degrees F. A fire extinguisher is also located in the kitchen.

Smoke/Carbon Monoxide Detectors – The detectors were tested at 11:25 am and were operable.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAUREL HOME
FACILITY NUMBER: 197610126
VISIT DATE: 08/22/2023
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Resident Bedrooms - There are four bedrooms in the home which are furnished with a bed, linens, night stand, chest of drawers and a closet.

Backyard - LPA observed the backyard which has a shaded area with seating.

LPA observed the garage which is used as the Administrator's office. The resident and staff records were securely locked in the garage.

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: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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