197610167-6-21-2021-31-AS-MSPH-C47RDJ-20210621125601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610167
Report Date: 06/21/2021
Date Signed: 06/21/2021 12:57:16 PM

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:	OHANA ELDERLY CARE, INC		FACILITY NUMBER:	197610167
ADMINISTRATOR:	ARAYATA, NATIVIDAD		FACILITY TYPE:	740
ADDRESS:	3052 W. MILLING ST		TELEPHONE:	(661) 940-5855
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	06/21/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Natividad Arayata		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Melissa Spaeth conducted pre-licensing visit to the facility and met with Administrator Natividad Arayata and Licensee, Beatriz Vasquez. LPA explained to both parties the purpose of the visit was to conduct the Comp III presentation, to inspect physical plant, and to ensure the facility is meeting Title 22 General Regulations. LPA Spaeth confirmed there are currently five non ambulatory residents living in the facility. LPA Spaeth entered the facility at 9:05 am and LPA observed the appropriate COVID-19 signs on the door. LPA’s temperature was taken and recorded by Administrator and LPA signed in at the front door of the facility. LPA Spaeth also observed masks and hand sanitizer available for visitors. The physical plant is a single family dwelling with five resident rooms, staff room, and four bathrooms. LPA Spaeth began the tour by observing the living room and formal dining room. LPA was escorted to a large room which is the kitchen and family combined together. LPA observed the kitchen contained a kitchen table where two residents were social distanced. LPA observed an adequate supply of fresh fruits and vegetables within the refrigerator, frozen meats, vegetables, and ice cream within the freezer section. The Administrator unlocked a kitchen drawer which contained the knives. The Administrator opened the cabinets under the sink and LPA observed there were no cleaning supplies stored underneath the sink. LPA Spaeth observed wash your hands sign, hand soap, and paper towels at the kitchen sink. Administrator unlocked a kitchen cabinet and LPA observed plastic containers labeled with each resident’s names and contained residents’ medications. LPA also observed an adequate supply of canned goods within the pantry and also observed the fire extinguisher in the kitchen. LPA Spaeth checked the water temperature in the kitchen at 9:15 am which measured 111.7 degrees F.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OHANA ELDERLY CARE, INC	FACILITY NUMBER: 197610167
	VISIT DATE: 06/21/2021

NARRATIVE

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All parties then entered a hallway to the left and LPA observed cabinets which contained an adequate supply of linens for the residents. To the left of the supply cabinet, LPA observed the staff/visitor bathroom which contained wash your hands sign, hand soap, paper towels, and a trash can. Upon exiting the bathroom, LPA was led to Room 1, which is the master bedroom for a bedridden resident. LPA observed the master bath which contained all the CCL requirements (hand soap, wash hands sign, paper towels, and trash can). LPA was then escorted to Room 2 and Room 3 which both contained necessary CCL requirements which is bed, lamp, lamp stand, chair, and closet space for clothing. Each resident room contained an exit door and Administrator demonstrated to LPA the alarms on each door throughout the facility were properly working.

LPA Spaeth then observed the laundry room which contained locked cabinets, washer and dryer. LPA Spaeth observed all cleaning supplies and laundry detergent locked in the cabinets. LPA Spaeth observed the staff room was locked. LPA was then escorted to Rooms 4 and 5. Both rooms contained lamp, night stand, chair, and closet. LPA Spaeth also observed two full baths within the facility for resident use which contained hand soap, wash your hands sign, paper towels, and trash can. LPA Spaeth was led to the backyard and LPA observed the gate leading to the front yard was not locked. LPA was then led to the garage which contained water and other supplies. The smoke/carbon monoxide detectors were located throughout the facility. The detectors were checked at 10:35 am and were properly working. LPA Spaeth observed the facility was neat and clean.

There were no deficiencies to report at this time. Exit interview was conducted, report read to the Administrator and Licensee. Administrator signed the report and a copy of the report sent to Administrator via email.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC809 (FAS) - (06/04)

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