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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610218
Report Date: 12/23/2021
Date Signed: 12/23/2021 01:13:18 PM

Document Has Been Signed on 12/23/2021 01:13 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:ALBARIDA ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197610218
ADMINISTRATOR:ALBARIDA, OSCARFACILITY TYPE:
735
ADDRESS:41853 YUMA COURTTELEPHONE:
(818) 572-5709
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
12/23/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Oscar AlbaridaTIME COMPLETED:
01:10 PM
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LPA Spaeth conducted a pre-licensing visit and was greeted by Oscar Albarida at 10:20 am. LPA observed the COVID signs on the front door, and the sign in station which contained hand sanitizer, thermometer, and sign in sheet. LPA's temperature was teken before entering the facility. LPA Spaeth conducted the COMP III presentation from 10:30 am until 11:30 am. At 11:30 am, LPA and Administrator toured the facility.

Living Room/Dining Room Combination - LPA observed the living room and dining room are combined together. The living room section contained comfortable seating and a television and the dining room contained a dining room table with chairs.

Kitchen - LPA observed the knives were locked in a cabinet, dish soap locked underneath the kitchen sink, wash your hands sign, hand soap, paper towels, and trash can within the kitchen. LPA observed fresh vegetables, fresh fruit, and frozen vegetables and frozen meats within the frozen section. LPA observed the pantry contained an adequate supply of canned vegetables, canned fruit, and pasta. The facility contained a five day supply of perishable foods and a one week supply of non-perishable foods. LPA observed the first aid kit which contained tweezers, scissors and bandages. At 11:27 am, LPA tested the water temperature and recorded the ready was 106.5 degrees F. LPA observed two fire extinguishers in the kitchen area.

Family Room - LPA observed a large family room which contained a location for the medications, which were properly locked. LPA observed the medications were neatly organized and the medications were bubble packed with resident's names on the bubble pack packages.

Downstairs bathroom- LPA observed the bathroom which contained a sink and toilet. The bathroom also contained wash your hands sign, hand soap, paper towels, and a trash cash. The bathroom was neat and clean.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ALBARIDA ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197610218
VISIT DATE: 12/23/2021
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Garage- The Administrator unlocked the door that led to the garage and LPA observed an adequate supply of PPE items stored in the garage. A refrigerator and freezer are also located in the garage and were both stocked with additional frozen foods and dairy products.

Laundry Room - The Administrator unlocked the laundry room and LPA observed a washer and dryer, laundry detergent, and cleaning supplies within the room.

Backyard - LPA and Administrator exited through the sliding glass door to the backyard. LPA observed covered area with comfortable seating. The gate that leads to the swimming pool was locked. A staff room is located at the west side of the facility and can be accessed through a sliding glass door from the backyard. LPA observed the room was locked but Administrator unlocked the door and LPA observed a bed and chairs. LPA observed the side gate that leads to the front yard was unlocked.

Upstairs Bathrooms- LPA and Administrator then walked up the stairs to the second level of the facility. LPA observed there are two bathrooms which contained wash your hands sign, hand soap, paper towels, and trash cans.

Resident Sitting Room - LPA observed a bedroom which contained a couch and chairs and LPA observed three residents watching television with a caregiver. Administrator stated the room is used as a sitting room so that residents can watch television and be close to the resident bathroom.

Residents' Rooms - LPA observed three resident rooms. The first room contained two full beds which were social distanced. The next resident room contained one bed and the female resident room also contained a full bed. All rooms contained lighting, bed, linens, chair, and chest of drawers. The rooms were neat and clean.

A locked staff room was located on the second floor and LPA observed a bed available for a staff member. Linens and hygiene items were locked in an upstairs cabinet area.

Carbon Monoxide/Smoke Detectors - At 11:56 am, Administrator tested the system which was properly working.

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

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC809 (FAS) - (06/04)
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