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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610218
Report Date: 11/06/2024
Date Signed: 11/06/2024 02:16:30 PM

Document Has Been Signed on 11/06/2024 02:16 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:ALBARIDA ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197610218
ADMINISTRATOR/
DIRECTOR:		ALBARIDA, OSCARFACILITY TYPE:
735
ADDRESS:41853 YUMA COURTTELEPHONE:
(818) 572-5709
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:OSCAR A. ALBARIDATIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by the Administrator, Oscar Albarida. LPA Spaeth stated the purpose of the visit was to conduct the annual inspection. The facility is licensed for four ambulatory clients. During the visit, LPA observed the clients were leaving the facility to attend the adult day program.

LPA Spaeth reviewed resident's files and P&I funds at 8:45 am until 9:35 am.

LPA Spaeth reviewed the staff files at 9:45 am until 10:10 am.

LPA and Administrator began the tour at 10:15 am until 10:45 am and observed the following:

Living Room/Dining Room Combination - LPA observed the living room and dining room are combined together. The living room section contained comfortable seating and the dining room contained a dining room table with chairs. LPA observed the residents’ medications were safely locked in the dining room closet. Additional PPE is also stored in a dining room cabinet.

Kitchen - The knives were locked in a cabinet. The dish soap, and cleaning supplies were locked underneath the kitchen sink. There is a seven-day supply of non-perishable food and a two day supply of perishable food items. LPA observed the first aid kit was locked in a kitchen cabinet. LPA observed the fire extinguisher.

Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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: ALBARIDA ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197610218
VISIT DATE: 11/06/2024
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Family Room - LPA observed a large family room which contained comfortable seating and full screen projector for watching movies and television.

Bathrooms- LPA observed the bathrooms which contained hand soap, paper towels, and a trash cash. The bathrooms were neat and clean.

Backyard – The backyard is shaded and contains comfortable seating. The pool is surrounded by a locked gate. The music room is located on the west side of the backyard property. .

Garage- A freezer is located in the garage.



Laundry Room - The room was locked and contained the washer/dryer and laundry detergent.

Residents' Rooms - LPA observed three resident rooms contained night lamp, night stand, bed, linens, chair, and chest of drawers. The rooms were neat and clean.

Locked staff room was located on the second floor and was locked.

Carbon Monoxide/Smoke Detectors - The carbon monoxide/smoke detectors were tested at 10:45 am and were properly working.

Water Temperature - the water temperature was tested at 10:45 am and was 120. degrees F.

LPA reviewed the resident's medications at 10:45 am until 11:00 am.

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

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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