197610180-6-15-2021-31-AS-JGTN-C3ZRJH-20210615130359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610180
Report Date: 06/15/2021
Date Signed: 06/15/2021 01:04:38 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:	FRANCES MANOR II		FACILITY NUMBER:	197610180
ADMINISTRATOR:	PROVOST, EDDI		FACILITY TYPE:	740
ADDRESS:	25690 YUCCA VALLEY RD		TELEPHONE:	(323) 919-9331
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 5	DATE:	06/15/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:48 AM
MET WITH:	Paul Thompson - Administrator		TIME COMPLETED:	12:00 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 Analysts (LPA) Gary Tan and LaQueena Lacy conducted an announced Pre Licensing visit to this facility and met with applicant representative Paul Thompson and administrator Eddi Provost. The applicant is "MOTHER MARYS BLESSED CARE LLC". Fire Clearance dated 5/20/2021 was received for six (6) non-ambulatory residents, of which one (1) may be bedridden in Room #3. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. The facility is a single storey building, Today's site visit consisted of LPAs touring the physical plant inside and outside and observed the following: The facility dual smoke/carbon monoxide alarm system is hard wired and interconnected. The fire extinguisher is located in the kitchen and was observed to be fully charged and was last inspected on 11/24/2020. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested and observed to be operational. Hot water was tested in the common bathroom and measured at 118.6°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are four (4) resident bedrooms, two (2) private and two (2) shared room. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records are stored in a locked filing cabinet in the living room area. Medications are stored in a locked cabinet in the kitchen area. The first aid kit is readily available. There are two (2) bathrooms in the facility. One (1) bathroom is designated for staff and visitors' use only and was observed to be locked. The common bathroom has non-skid mat and appropriate grab bars installed. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FRANCES MANOR II	FACILITY NUMBER: 197610180
	VISIT DATE: 06/15/2021

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(continued from LIC 809)

The kitchen knives are stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the garage. The laundry area is located in the hallway near the exit to the garage. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is attached to the house and observed to be locked during the visit. The garage is currently being used as emergency and perishable food, PPE and other supplies storage. The spa is currently empty and was observed to be locked and appropriately fenced.

Component III was waived as the licensee representative took it under the prior license issued in 2019.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Licensee Representative Paul Thompson and a copy of this report was provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC809 (FAS) - (06/04)

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