<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610168
Report Date: 08/23/2024
Date Signed: 08/23/2024 12:31:53 PM

Document Has Been Signed on 08/23/2024 12:31 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/
DIRECTOR:		ROYO, MARIA CECILIAFACILITY TYPE:
735
ADDRESS:43230 PALOMA CTTELEPHONE:
(818) 642-7742
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Maria RoyoTIME VISIT/
INSPECTION COMPLETED:
12:30 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) Evelin Rios conducted an Annual Required visit and inspection of this facility. LPA met with staff#1(S1) who granted access. S1 contacted the administrator Maria Royo and informed them LPA was at the facility. Administrator met LPA shortly after and LPA explained the reason for the visit.

LPA along with the administrator conducted a tour of the physical plant and LPA observed the following:

The home is a one story dwelling. The facility has an approved fire clearance for two (2) non ambulatory and two (2) ambulatory clients for a total capacity of four (4). Upon entry LPA observed required postings on facility wall.

Common Areas: These included the living areas and dining area. The common areas were clean and clear of clutter. The areas were properly furnished. Dining table with chairs and sofas sit the capacity of the facility. LPA observed an area by the kitchen with a facility computer and games for clients to use.

Garage and Laundry: The garage is attached and entry to the garage from the facility 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 locked garage. There is extra PPE stored in the garage.

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 bed, night stand, a chair, appropriate bedding, and have sufficient lighting.

Bathrooms: There are two (2) bathrooms in the facility. The shared bathroom is properly supplied with toilet paper, hand soap and paper towels. (Continue to LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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: 08/23/2024
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
26
27
28
29
30
31
32
LPA observed three closets. Closets store emergency supply of food and water, PPE, extra linens, and toiletries. LPA observed a locked closet that stored cleaning supplies.

Surrounding Grounds: Entry/exits were free of obstruction. There is a covered patio, furniture appropriate for outdoor use and exercise equipment for clients. No bodies of water observed. There are two storage sheds that were observed locked.

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

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

The smoke alarms are hardwired and interconnected. The facility has a carbon monoxide detector in the dining area. Detectors were tested at 9:43 a.m. and were observed operational. LPA observed one (1) fire extinguisher with serviced date of 05/01/2024.

Client/Staff Records: At approximately 10:00 a.m. four (4) out four (4) client records and six (6) out of six (6) staff records were reviewed to insure compliance with licensing forms. No issues found.

Medications: Medications were observed locked in a cabinet in the office. Centrally Stored Medication and Destruction records were reviewed for proper documentation at 10:40 a.m. Records are maintained manually. Facility also maintains Medication Administration Records (MARs). LPA observed a first aid kit with manual.


Pursuant to Title 22 Division 6 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: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2