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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610205
Report Date: 10/31/2024
Date Signed: 10/31/2024 01:33:11 PM

Document Has Been Signed on 10/31/2024 01:33 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:HUMBLE HAVEN RCFE IIIFACILITY NUMBER:
197610205
ADMINISTRATOR/
DIRECTOR:		DE LAS ALAS, NICOLEFACILITY TYPE:
740
ADDRESS:38433 ANSET DRIVETELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Raquel Adriano & Jeffrey BuendiaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregivers. The Administrator Nicole De Las Alas was called. LPA stated the purpose of the visit was to conduct an annual inspection. The caregivers confirmed there are five residents. The facility is licensed for five (5) non-ambulatory residents and one bedridden resident.

LPA Spaeth and the caregiver toured the facility at 10:00 am until 10:30 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 area contained a dining room table and chairs.

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

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

Continued on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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: HUMBLE HAVEN RCFE III
FACILITY NUMBER: 197610205
VISIT DATE: 10/31/2024
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Staff Room – The staff room was locked.

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

Bathrooms: The bathrooms contained hand soap, paper towels, grab bars, trash can, and slip resistant mats.

Water Temperature: The water temperature was tested at 10:40 am and was 110 Degrees F.

Hallway Cabinet- LPA observed the clean linens were located in a cabinet.

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 the backyard in a shaded area

Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested at 11:30 am and were operable.

LPA Spaeth reviewed the resident files at 10:45 am until 11:07 am and reviewed the staff staff files at 11:07 am until 11:20 am. LPA reviewed the medications at 11:30 am until 11:55 am.



There are no deficiencies to report at this time. Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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