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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610205
Report Date: 10/14/2022
Date Signed: 10/14/2022 05:13:26 PM


Document Has Been Signed on 10/14/2022 05:13 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:HUMBLE HAVEN RCFE IIIFACILITY NUMBER:
197610205
ADMINISTRATOR:DE LAS ALAS, NICOLEFACILITY TYPE:
740
ADDRESS:38433 ANSET DRIVETELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 6DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marco Fernando and Jelesa KapileoTIME COMPLETED:
03:21 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and was greeted by two caregivers who were wearing a mask. LPA observed the COVID signs at the front door and the sign in station. LPA's temperature was recorded. LPA stated the purpose of the visit and Administrator was called at 2:45 pm. and LPA spoke to Administrator. Caregivers confirmed there are six residents within the facility.

LPA observed the five resident rooms which all contained bed, linens, night stand, lamp, and chest of drawers. LPA observed the master bedroom is shared by two male occupants. The room is large and spacious. The hallway closet contains PPE and linens. LPA observed the locked laundry room which contained laundry detergent, resident hygiene items, and cleaning supplies were locked in a cabinet. The garage door was locked.. LPA observed comfortable seating in the backyard and the gate leading from the backyard to the front yard was not locked.
The kitchen was clean and the kitchen cabinet underneath the sink was locked and contained some cleaning supplies. The resident medications are locked in a kitchen cabinet. LPA observed a seven day supply of canned goods but there was not a two day supply of fresh fruits and vegetables. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

LPA Spaeth Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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Document Has Been Signed on 10/14/2022 05:13 PM - It Cannot Be Edited

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: HUMBLE HAVEN RCFE III
FACILITY NUMBER: 197610205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited

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General Food ServicesRequirements (b) The following food service requirements shall apply: (26) Supplies of …perishable foods for a minimum of two days shall be maintained on the premises. This evidenced by:
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LPA Spaeth observed the refrigerator contained a limiited amount of fresh fruits and vegetables which poses a health risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2