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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610210
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:48:06 PM


Document Has Been Signed on 10/19/2022 12:48 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:CASTLEMERE SENIOR HOME IIFACILITY NUMBER:
197610210
ADMINISTRATOR:JOSEPH-NURSE, VERONICAFACILITY TYPE:
740
ADDRESS:23780 VIA IRANATELEPHONE:
(661) 888-0432
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 3DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Resty Angeles, StaffTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Angela Panushkina conducted a required annual visit to this facility. LPA met with the staff members, Editha Lambino and Resty Angeles, who granted access to the facility and then contacted the Administrator and LPA explained the reason for the visit. Administrator was not able to come to the facility and designated staff to sign for the report.

Upon arrival LPA was screened and asked to sign-in visitor’s log. LPA observed two (2) residents in the dining room area having lunch. At approximately, 11:50am LPA conducted physical tour inside and outside to ensure compliance with Title 22 regulations. LPA toured resident bedrooms and bathrooms. All bedrooms had the required furniture. All bathrooms had grab bars. Water temperature was checked in the resident’s restroom and temperature was 113.0*F. Common areas were also checked. LPA reviewed the food service areas and food supply and observed enough perishable foods for two days and nonperishable for one week. The storage of toxic and hazardous items, knives and medication cabinet was observed locked/inaccessible to residents. LPA reviewed medication and medication documentation. The Administrator has active certificate with expiration date of 10/24/2022. Staff and resident’s records reviewed. All staff have active first aid card and fingerprint clearance. Residents records reviewed to ensure there is a current signed admission agreement on file, current medical assessment, TB clearance and current needs and services.

LPA observed fire extinguisher located in the kitchen area and it was last serviced on 08/03/2022. At 12:10pm, smoke and carbon monoxide detectors were tested and observed to be operable. First Aid kit reviewed for required items and manual.

No Deficiencies cited during visit.

Exit interview conducted and Appeal Rights discussed. Copy of report provided.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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