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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610168
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:54:40 PM

Document Has Been Signed on 12/08/2023 03:54 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
N LA & CEN COA AC/SC, 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: 4DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Hyler Royo - StaffTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted an Annual Required visit and inspection of the facility. LPA met with staff, Hyler Royo and explained the reason for the visit. LPA spoke with the administrator Maria Cecilia Royo over the telephone to explained the purpose of the visit. Administrator could not meet LPA at the facility and designated staff to sign todays report.

LPA and staff took a tour of the physical plant and LPA observed the following:

The home is a one story building. Annual fees are current. The facility has fire clearance for two(2) non ambulatory and two (2) ambulatory clients. Upon entry LPA observed required postings on facility wall.

Common Areas: These included the living rooms and dining area. The common areas were properly furnished. Dining table and couches sit the capacity of the facility.

Kitchen: The kitchen appliances and fixtures were maintained and kept clean. LPA observed the facility to have a sufficient amount of 7 day non-perishable and 2 day perishable food; properly stored. Knives and sharps are kept locked in a kitchen drawer.

Bedrooms: There are four (4) client bedrooms, for single use. One (1) additional bedroom is designated for staff use. Client bedrooms were observed to be appropriately furnished with appropriate bedding, linens and have sufficient lighting.

Bathrooms: There are two (2) bathrooms in the facility. One (1) bathroom is designated for staff use only. The shared bathroom is properly supplied with toilet paper, hand soap and paper towels. Hot water temperature was measured at 109.4 degrees Fahrenheit at 1:21 p.m.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HARCELLE RESIDENTIAL HOME CARE
FACILITY NUMBER: 197610168
VISIT DATE: 12/08/2023
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The smoke alarms are hardwired and interconnected. The facility has a carbon monoxide detector in the dining area. Detectors were tested at 1:26 p.m. and were observed operational. LPA observed two (2) fire extinguishers fully shared with serviced date of 05/24/2023.

Closet: There is a closet by the entrance of the facility door where the facility stores an emergency supply of food and water. LPA also observed PPE.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards.

Garage and Laundry: The garage is attached and is kept locked. The laundry area is by the garage door and is accessible to clients. The detergents and extra facility supplies are kept in the lock garage. There is an extra freezer in the garage with an over flow of frozen food for the facility.

Office: Client, staff records, medication and medication records are kept locked in the facility office.

Client/Staff Records: At approximately 1:30 p.m. four (4) out four (4) client records and three (3) staff records were reviewed to insure compliance with licensing forms.

Medications: Medications and records were observed locked. Medication Records were reviewed for proper documentation. Medication records are maintained manually. Facility maintains Medical Administration Records (MAR).


Pursuant to Title 22 Division of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC809 (FAS) - (06/04)
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