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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610193
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:15:53 PM


Document Has Been Signed on 08/26/2024 04:15 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:A HOME FOR MOM & DADFACILITY NUMBER:
197610193
ADMINISTRATOR:APOLINARIO, EMMA L.FACILITY TYPE:
740
ADDRESS:44856 33RD STREET WTELEPHONE:
(661) 418-0016
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Emma Apolinario and Amante ApolinarioTIME COMPLETED:
04:30 PM
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On 08/26/24 at 1:00 p.m. Licensing Program Analyst (LPA) Evelin Rios conduct an unannounced annual inspection. LPA was greeted by administrator, Emma Apolinario. Upon entry LPA observed required postings, hand sanitizer, and a visitor sign in log. LPA also met with Licensee, Amante Apolinario. LPA explained the purpose of the visit. The facility is a two story home with a fire clearance for five (5) non-ambulatory residents and one (1) bedridden resident for a total capacity of 6 residents.

At approximately 1:05 p.m. LPA along with administrator conducted a physical plant tour inside and out and the following was observed:

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Medication was observed stored in a locked kitchen cabinet.

Bedrooms: There are five (5) bedrooms designated for residents' use. One (1) bedroom is currently vacant. Bedroom #1 can be shared. Rooms occupied by residents were properly furnished with appropriate beddings, linens and with sufficient lighting.

Bathrooms: There is (1) bathroom designated for residents' use. Bathroom was properly supplied with hand soap, toilet paper, paper towels and had functional fixtures. Hot water temperature read 118 degrees Fahrenheit.

Common Areas: These included the living area and dining area. The common areas were clean and properly furnished.
(Continued to LIC809-C)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A HOME FOR MOM & DAD
FACILITY NUMBER: 197610193
VISIT DATE: 08/26/2024
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The smoke alarms are interconnected. LPA observed a carbon monoxide detector in the hallway leading to the bedrooms. Carbon monoxide detector was functioning properly. Licensee tested smoke detectors at 2:23 p.m. and were observed to be functioning properly. There are two (2) fire extinguishers located by the kitchen and they were observed fully charged.

Surrounding Grounds: The outdoor area was free of hazards and has a gazebo with outdoor furniture. LPA observed four (4) sheds used for storage.

Laundry room/Garage: Detergents and cleaning products are kept in the locked laundry room inaccessible to residents. LPA observed a washer. Door leading to the garage was locked. In the garage LPA observed a dryer and cleaning chemicals.

Resident Files: LPA conducted a file review of four (4) out of four (4) resident records to insure compliance of licensing forms.

Medications: At 3:30 p.m. LPA and the licensee reviewed Centrally Stored Medication and Destruction Records for proper documentation. Facility also keeps Medication Administration Records (MARs).

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 this report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC809 (FAS) - (06/04)
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