197610180-6-9-2022-31-AS-APAA-CF8S8E-20220609133901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610180
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:39:46 PM

Document Has Been Signed on 06/09/2022 01:39 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FRANCES MANOR II		FACILITY NUMBER:	197610180
ADMINISTRATOR:	PROVOST, EDNA		FACILITY TYPE:	740
ADDRESS:	25690 YUCCA VALLEY RD		TELEPHONE:	(323) 919-9331
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 5	DATE:	06/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Paul Thompson, Administrator		TIME COMPLETED:	02:10 PM

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At 12:00pm Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by Dina Flores, who granted access to the facility. The Administrator arrived shortly after and LPA explained the reason for the visit.

At 12:05pm, LPA conducted a tour of the facility and the following was observed:

Infection control: Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. Fire extinguisher in the kitchen was last serviced on 11/05/2021.

Medications: At approximately, 12:15pm LPA observed medications are centrally stored and locked in the kitchen cabinet and inaccessible to residents in care.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: At 12:25am LPA observed all bathrooms are clean and in good repair. Properly supplied with

toilet papers, soap and paper towels. The hot water temperature measured at 110.4°F.
Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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: 06/09/2022

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LPA observed appropriate grab bar and non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 12:30pm they were tested and observed to be operational.

Common Areas: The facility maintains a comfortable temperature at 78°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Outside areas: At approximately, 12:35pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The spa is currently empty and was observed to be locked and appropriately fenced. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents.

The garage: The garage is currently being used for extra food, PPE and other supplies storage.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC809 (FAS) - (06/04)

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