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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610205
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:31:31 PM

Document Has Been Signed on 10/14/2021 12:31 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: 0DATE:
10/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Nicole De Las AlasTIME COMPLETED:
12:15 PM
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LPA Spaeth conducted a Comp III presentation and pre-licensing visit and was met at the front door by the Administrator, Nicole De Las Alas. LPA observed the required COVID signs posted on the front door. LPA observed the Administrator was wearing a mask. LPA's temperature was taken and the COVID questions were asked by Administrator. LPA signed in and observed hand sanitizer and masks available for use.

LPA conducted the Comp III presentation from 10:05 am until 10:20 am. The tour began at 10:22 am. LPA checked the water temperature in bathroom #1 and recorded the temperature to be 107.8 F at 10:24 am.

Resident bedrooms - LPA observed six bedrooms which contained a bed, linens, chest of drawers, night stand, night lamp, and chair in each room. Each room was specious and clean. LPA observed bedroom #5, which is designated for a bedridden resident. LPA observed the exit door contained the alarm and was tested operable at 11:36 am.

Kitchen - LPA observed the kitchen contained the wash your hands sign, hands soap, paper towels, and trash can. LPA observed an adequate supply of fresh vegetables, fresh fruits, dairy products, and frozen meats within the refrigerator. LPA observed the pantry contained an adequate supply of canned goods. The Administrator unlocked the cabinet underneath the kitchen sink and observed the cleaning supplies stored in the cabinet. LPA observed the locked cabinet which is designated for resident medications. LPA observed the fire extinguisher located in the kitchen.

Bathrooms - LPA observed three bathrooms which contained wash your hands sign, hand soap, trash cans, grab bars, and slip resistant mats. All bathrooms were neat and clean.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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: HUMBLE HAVEN RCFE III
FACILITY NUMBER: 197610205
VISIT DATE: 10/14/2021
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Outdoor area - LPA Spaeth observed safe patio furniture and observed the gate exiting from the backyard to the front yard was not locked.

Laundry Area- LPA observed the laundry room which contained washer and dryer and a locked cabinet which contained laundry detergent.

LPA Spaeth observed an adequate supply of PPE and emergency water. The smoke detector/carbon monoxide was tested at 10:45 am and was working throughout the facility.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed and a copy of the report was emailed to the administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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