197610242-7-18-2023-31-AS-MSPH-CTUTSQ-20230718145927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610242
Report Date: 07/18/2023
Date Signed: 07/18/2023 02:59:37 PM

Document Has Been Signed on 07/18/2023 02:59 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:	PROVIDENCE MANOR, LLC, THE		FACILITY NUMBER:	197610242
ADMINISTRATOR:	DE LIMA, MARY ANN N		FACILITY TYPE:	740
ADDRESS:	3434 TAMARISK DRIVE		TELEPHONE:	(661) 526-4322
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 5	DATE:	07/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mary Ann De Lima		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/18/2023 at 10:30 am, Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced required annual visit and was greeted by the Administrator. LPA Spaeth confirmed there are five non ambulatory residents with one bedridden and two Hospice residents. The facility is licensed as an RCFE to serve six residents of which six may be non-ambulatory and two may be bedridden. There is a hospice waiver Kitchen – LPA observed a seven-day supply of non-perishable food and a two day supply of perishable food items. At 9:55 am, LPA observed the cleaning supplies were securely locked underneath the kitchen sink and the knives were locked in a kitchen drawer. The medications are locked in a kitchen cabinet and LPA also observed the first aide kit. A fire extinguisher is also located in the kitchen area. Backyard – LPA Spaeth observed the delayed egress alarm leading out of the sliding glass door to the backyard was properly working. The backyard is a shaded area which contained comfortable seating. The side gate leading from the backyard to the front yard was not locked. Bedrooms – LPA Spaeth observed there are two residents living in the master bedroom. The delayed egress alarm leading from the bedroom to the backyard was properly working. The room contained bed, linens, night stand, and night lamp. LPA also observed the other three bedrooms also contained the required bed, linens, night stand and night lamp. The delayed egress alarm properly worked throughout the facility. Bathrooms – At 10:15 am, LPA tested the water temperature in the resident’s bathroom and LPA observed the reading was 106.7 degrees F. LPA Spaeth observed both bathrooms contained slip resistant mats, hand soap, paper towels, and trash can. Continued on 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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: PROVIDENCE MANOR, LLC, THE	FACILITY NUMBER: 197610242
	VISIT DATE: 07/18/2023

NARRATIVE

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Common Areas – LPA observed comfortable seating in the living room and family room. The dining area contained a dining room table and chairs.

Smoke/Carbon Monoxide Detectors -The smoke detectors were tested at 10:50 am and were operable. The carbon monoxide detector was also operable.

LPA reviewed residents’ files at 10:55 am until 11:19 am. LPA reviewed staff files at 11:20 am until 12:10 pm. LPA interviewed three resident at 1:15 pm until 1:40 pm and interviewed two staff members at 1:40 pm until 1:50 pm

There are no deficiencies to report. Exit interview conducted, and a signed copy of the report was given to the Administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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