197610201-10-29-2021-31-AS-MSPH-C89RGZ-20211029130134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610201
Report Date: 10/29/2021
Date Signed: 10/29/2021 01:03:03 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:	4 ALL SENIORS CARE HOME		FACILITY NUMBER:	197610201
ADMINISTRATOR:	SAMANIEGO, JOHN ROEL		FACILITY TYPE:	740
ADDRESS:	744 VANDALWAY		TELEPHONE:	(661) 400-4948
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 6	DATE:	10/29/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	John Roel Samaniego and Marita Samaniego		TIME COMPLETED:	01:15 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	LPA Spaeth arrived to the facility at 10:15 am and was greeted by Marita Samaniego eand John Roel Samaniego. LPA observed the COVID 19 signs on the front door. LPA's temperature was taken, COVID symptom questions were asked, and LPA was asked to sign in. LPA observed the sign in station which contained sign in sheet, thermometer, hand sanitizer, wash your hands sign, and masks. LPA Spaeth was escorted through the facility at 10:40 am. LPA observed Bedrooms 4 and 5 on the north side of the property. The bedrooms contained a bed, linens, night stand, lamp, chest of drawers, and chair. All rooms were neat and clean. LPA then observed a staff/visitor bathroom which contained wash your hands sign, hand soap, paper towels, grab bars, and trash can. The shower area contained a slip-resistant mat. LPA observed the garage which contained a lock on the door. The garage contained a supply of emergency water, boxes of PPE, and a refrigerator which contained frozen meats and other produce. The medications were properly locked in a closet along with PPE supplies and the first aid kit. LPA observed the kitchen/family room/dining room. LPA observed wash your hands sign, paper towels, hand soap, and trash can. The knives were locked in a kitchen drawer and the dish soap was locked underneath the sink. LPA observed residents playing bingo in the dining room area. The family room contained comfortable furniture and a television. LPA then observed the resident rooms on the south side of the facility. There are three rooms which contained all the necessary requirements. At 10:50 am, LPA tested the water temperature which read 109.7 degrees F. The bathroom contained wash your hands sign, hand soap, paper towels, trash can, grab bars, and slip resistant mat. The laundry room was locked and contained cleaning supplies, additional PPE, and available resident hygiene items. Upon exiting to the backyard, LPA observed comfortable seating for residents and the side gate was not locked.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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: 4 ALL SENIORS CARE HOME	FACILITY NUMBER: 197610201
	VISIT DATE: 10/29/2021

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Administrator tested the smoke detectors and carbon monoxide detector at 11:10 am and LPA observed the detectors were fully functional. LPA also observed two fire extinguishers in the facility which were fully charged. LPA observed the entire facility was clean and all staff were wearing masks. LPA also observed COVID signs posted throughout the facilty and the Let Us No sign was also posted.

Since residents were playing Bingo in the dining room/family room area, LPA conducted the COMP III presentation from 11:15 am until 12:20 pm. in the backyard. There are no deficiencies to report at this time.

Exit interview as conducted, appeal rights discussed, and a copy of the report was printed for the Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC809 (FAS) - (06/04)

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