197610168-8-5-2025-31-AS-ERIS-DK9P2H-20250805105558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610168
Report Date: 08/05/2025
Date Signed: 08/05/2025 10:56:07 AM

Document Has Been Signed on 08/05/2025 10:56 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HARCELLE RESIDENTIAL HOME CARE		FACILITY NUMBER:	197610168
ADMINISTRATOR/ DIRECTOR:	ROYO, MARIA CECILIA		FACILITY TYPE:	735
ADDRESS:	43230 PALOMA CT		TELEPHONE:	(818) 642-7742
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 4		CENSUS: 4	DATE:	08/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Maria Cecilia Royo		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

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 unannounced Annual Required visit and inspection of this facility. LPA met with the administrator Maria Cecilia Royo and LPA explained the reason for the visit. In the facility LPA met three (03) out of four (04) clients. Clients were getting ready to be picked up for their community programs. At approximately 8:20 a.m., LPA conducted a facility file review. The facility is licensed to serve two (2) ambulatory and two (2) non-ambulatory clients, for a total capacity of four (4). Administrator certification is current. LPA reviewed current Surety bond and Certificate of Liability Insurance. LPA reviewed facility's annual emergency disaster training that was conducted 01/10/2025. Last fire drill was conducted on 05/14/2025. Client roster and 24 hour staff schedule were reviewed to ensure they are current and complete. Staff and Records: At 8:54 a.m., LPA Rios reviewed four (04) two staff records to enure compliance with licensing forms. At approximately 9:05 a.m., LPA reviewed four (4) out of four (04) client records to ensure they were current and complete. At 9:43 a.m., LPA Rios, along with the administrator, conducted a physical plant tour of the facility—inside and out—and made the following observations. LPA observed required postings on facility wall along with a sign in log for visitors and residents by the entry. LPA observed a closet by the entrance that stored extra linens, emergency food, water and PPE. Office: Client, staff records, centrally stored medication, medication records and first aid kit with manual are kept in the office inside locked cabinets. LPA observed an extra refrigerator. (Continue to LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
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: 08/05/2025

NARRATIVE

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(Continued form LIC809) 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 were observed in good repair. Living room has a projector for clients. LPA observed a second living area with a television, the facility computer and games for clients to use.

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. Repackaged food was properly stored and labeled. Knives and sharps are kept locked in a kitchen drawer.

The smoke alarms are hardwired and interconnected. The facility has a carbon monoxide detector in the dining area. Detectors were tested at 9:52 a.m. and were observed operational. LPA observed two (2) fire extinguisher with serviced date of 05/08/2025.

Bedrooms: There are four (4) client bedrooms, for single use. Client bedrooms were observed properly furnished with bed, night stand, a chair, appropriate bedding, and have sufficient storage. Windows and windows screens were observed in good repair.

Bathrooms: The facility bathroom is properly supplied with toilet paper, hand soap and paper towels. The hot water temperature was taken at 10:04 a.m., and measured 109.8 degrees Fahrenheit, within regulation.

Garage and Laundry: The garage is attached and entry to the garage from the facility is kept locked. The laundry area is accessible and is equipped with a washer and dryer. The detergents, extra linens and hygiene products are kept locked in cabinets in the laundry area. The garage stores extra facility supplies.

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area had a covered patio that provides shade, and is furnished for outdoor use. No bodies of water observed. The backyard is entirely fenced in.

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 provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC809 (FAS) - (06/04)

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