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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610168
Report Date: 07/27/2022
Date Signed: 07/27/2022 11:28:00 AM

Document Has Been Signed on 07/27/2022 11:28 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:HARCELLE RESIDENTIAL HOME CAREFACILITY NUMBER:
197610168
ADMINISTRATOR:ROYO, MARIA CECILIAFACILITY TYPE:
735
ADDRESS:43230 PALOMA CTTELEPHONE:
(818) 642-7742
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 3DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Maria Cecilia RoyoTIME COMPLETED:
11:45 AM
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At 10:10 a.m. Licensing Program Analysts (LPA) Melissa Ruiz conducted an unannounced annual inspection at this facility. LPA was greeted by staff and later met with Administrator Maria Cecilia Royo, and an entrance interview was conducted.

At 10:30 a.m. a physical tour was conducted with the Administrator. This is a 5-bedroom, 2-bathroom facility. Infection control: Upon arrival, staff took LPA’s temperature, and was asked to sign-in the visitor’s log, which contained infection control questions. Proper signage was observed posted outside the facility and inside along the hallways. Hand sanitizer was also observed. LPA observed sufficient PPE supplies for clients and staff. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are kept inaccessible to residents. Medications are in a centrally stored and are kept locked in the office. Chemicals and cleaning supplies are kept locked and inaccessible in a designated closet in the hallway. Smoke detectors/carbon monoxide were located throughout the facility and were functional. Fire extinguishers were last serviced on 6/13/22. Client rooms: There are 4 bedrooms designated for clients. All bedrooms are properly furnished, have appropriate bedding, and linens. Bathrooms have paper towels, soap, and appear to be clean. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor seating, with various covered shaded areas for clients. There are no bodies of water. Administrative: LPA noted that the infection control plan has already been completed and submitted to the Woodland Hills Regional Office for approval.

No deficiencies observed at this time. Exit interview conducted and report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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