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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610201
Report Date: 10/27/2022
Date Signed: 10/28/2022 11:58:16 AM


Document Has Been Signed on 10/28/2022 11:58 AM - 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:4 ALL SENIORS CARE HOMEFACILITY NUMBER:
197610201
ADMINISTRATOR:SAMANIEGO, JOHN ROELFACILITY TYPE:
740
ADDRESS:744 VANDALWAYTELEPHONE:
(661) 400-4948
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 5DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:John Roel SamaniegoTIME COMPLETED:
03:30 PM
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LPA Spaeth conducted an unannounced visit and was met by Administrator who was wearing a mask. LPA stated the purpose of the visit was to conduct an annual visit. Administrator confirmed there are five residents in the facility. LPA was asked to sign in at the sign in station. LPA observed the thermometer, sign in sheet, masks, and hand sanitizer.

Upon entering the facility, LPA observed the family room/dining room/kitchen combination. LPA observed three residents watching television and were seated in comfortable recliners. LPA observed the facility was neat and clean. LPA was informed residents had played bingo earlier today. LPA observed a slot machine in the family room and a resident was enjoying playing.

LPA and Administrator began tour at 2:35 pm. LPA observed a three--day supply of fresh vegetables and fruits in the refrigerator. The pantry contained a seven day supply of canned goods. The knives were locked in a kitchen drawer. The cabinet underneath the sink was unlocked and contained the cleaning supplies. The medications and PPE were locked in a kitchen closet. The facility contains a 90-day supply of PPE.

LPA observed three residents' rooms all contained bed, linens, night stand, lamp and chest of drawers in each room. LPA observed the bathrooms contained wash your hands sign, paper towels, trash can, slip resistant mats and hand soap.

LPA also observed the staff room was locked and the laundry room was locked. LPA observed additional cleaning supplies along with washer/dryer, and laundry detergent were stored in the laundry room. The backyard contained shaded area with comfortable seating. The gate leading from the backyard to the front yard was not locked.
There are no deficiencies to report today. Exit interview conducted and copy of the report given to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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