197610201-10-23-2024-31-AS-MSPH-DABV3U-20241023160520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610201
Report Date: 10/23/2024
Date Signed: 10/23/2024 04:06:10 PM

Document Has Been Signed on 10/23/2024 04:06 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	4 ALL SENIORS CARE HOME		FACILITY NUMBER:	197610201
ADMINISTRATOR/ DIRECTOR:	SAMANIEGO, JOHN ROEL		FACILITY TYPE:	740
ADDRESS:	744 VANDALWAY		TELEPHONE:	(661) 400-4948
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 6		CENSUS: 4	DATE:	10/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Marita Samaniego		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit on 10/23/2024 and was greeted by the caregivers. The Administrator, Marita Samaniego arrived to the facility at 9:45 am.. LPA stated the purpose of the visit was to conduct an annual inspection. The caregivers confirmed there are four residents living in the facility. The facility is licensed for six (6) non-ambulatory residents and one bedridden resident. The facility has a hospice waiver for six residents.

LPA Spaeth and the caregiver toured the facility at 10:15 until 10:45 am.

Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room contained a dining room table and chairs.

Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a hallway closet.

Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher was located near the kitchen and was operable. The knives were locked in a kitchen drawer and the cleaning solutions were locked underneath the kitchen sink.

Laundry Room – The laundry room was locked and contained the washer/dryer, laundry detergent and additional cleaning solutions.

Continued on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: 4 ALL SENIORS CARE HOME	FACILITY NUMBER: 197610201
	VISIT DATE: 10/23/2024

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Garage – LPA observed an additional refrigerator which contained milk and frozen food items. Emergency water was located in the garage.

Bathrooms: There are two (2) resident bathrooms and one staff bathroom. All bathrooms were well lit, clean, contained hand soap, slip resistant mats, grab bars, paper towels and trash bins with lids. The water temperature was tested at 10:40 am and was 106.0 degrees F.

Resident Rooms: There are five resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean..

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in a shaded area in the backyard.

Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 10:45 am and were operable.

LPA reviewed resident files at 11:10 am until 11:30 am and reviewed staff records at 11:30 am until 12:00 pm. LPA reviewed resident medications at 12:20 pm. There are no deficiencies to report.

Exit interview conducted, and a copy of the signed report was given

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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