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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610173
Report Date: 06/01/2021
Date Signed: 06/01/2021 12:04:22 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:A MAHALO CARE VILLAFACILITY NUMBER:
197610173
ADMINISTRATOR:BLANCHARD, MARKFACILITY TYPE:
740
ADDRESS:38433 ANSET DRIVETELEPHONE:
(818) 983-9720
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 0DATE:
06/01/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mark Blanchard/ AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Patrick Shanahan conducted a scheduled prelicensing visit on this day.


LPA utilized the RCFE Prelicensing Inspection tool to review all eleven inspection domains, no deficiencies were observed.
This application is a is a new application. Facility is fire cleared for five non-ambulatory and one bedridden resident. Facility has six private bedrooms. All bedrooms were appropriately furnished. Facility has three bathrooms that had grab bars and non skid materials in the showers and tub.
LPA observed the living room areas to be appropriately furnished. LPA checked the kitchen for the ability to prepare and store food. All knives and sharp objects were locked away and inaccessible. LPA observed medication to be locked away and inaccessible from residents. LPA observed all doors to be properly alarmed. Facility has smoke detectors and carbon monoxide detectors. LPA observed the backyard to be free of clutter and debris. Component III was also completed during this visit.

You are not allowed to begin operating until you have been notified that your license has been approved by the CAU Analyst. Failure to comply could affect approval of your license.
Exit interview held and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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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