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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610250
Report Date: 11/06/2023
Date Signed: 11/06/2023 12:52:44 PM

Document Has Been Signed on 11/06/2023 12:52 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MY HIDDEN GEM LLCFACILITY NUMBER:
197610250
ADMINISTRATOR:AIDINOVA, SALBIFACILITY TYPE:
735
ADDRESS:2810 W AVENUE J12TELEPHONE:
(818) 383-1780
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Salbi AidinovaTIME COMPLETED:
01:15 PM
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On 11/06/2023 at 9:40 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by administrator Salbi Aidinova who granted access. Administrator was with one (1) client, client#1 (C1). LPA explained the reason for the visit. Staff #1 (S1) arrived at the facility shortly after.

At 9:50 a.m. LPA and the administrator toured the physical plant of the facility, and the following was observed.

Kitchen/ Dinning area: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed cleaning products, medications, facility files, knives and sharp items kept locked in a closet by the kitchen. LPA observed a sufficient amount of 2- day perishable and 7-day non-perishable food supply at the facility; properly stored. LPA observed the weekly menu on the fridge. LPA observed various kitchen cabinets with non-perishable foods. On one of the kitchen's walls LPA observed one (1) fire extinguisher fully charged with a last serviced date of 06/11/2023. Dining area had appropriate table and chairs to sit the capacity of the facility.

Living room: The facility has two (2) living areas. Both were observed clean and properly furnished. Two (2) fireplaces were observed secured with screens.

Bedrooms: There are a total of five (5) bedrooms, one (1) of which is designated for live-in staff. LPA inspected four (4) out of four (4) client bedrooms. Bedrooms are for private use. LPA observed each client room to be properly furnished with one bed, appropriate night stand, chair, beddings and with sufficient lighting and storage. LPA observed extra linens in the hallway outside the bedrooms.

(Continued on to LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MY HIDDEN GEM LLC
FACILITY NUMBER: 197610250
VISIT DATE: 11/06/2023
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(Continued LIC809-C) At 10:07 a.m. LPA observed the administrator test a smoke detector that is hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly. LPA observed a carbon monoxide detector in the kitchen.

Bathrooms: The facility has three (3) total bathrooms one (1) of which is in the staff bedroom for staff use. The LPA took water temperature from one (1) out two (2) bathroom sinks and temperature read 112.4 degrees F within regulation. LPA observed both bathrooms to be clean and properly supplied with toilet paper, paper towels and trash bins with lids.

Laundry/Garage: Laundry room is located by the bedrooms. Detergents, extra cleaning supplies, and toiletries where observed locked in a closet by the laundry room. Garage is located by the kitchen accessible to clients and staff. LPA observed extra pantry food. Administrator stated they have enough PPE to last more than 30 days.

Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for clients to use.

Client/Staff Records: At approximately 10:16 a.m. four (4) out four (4) client records and (2) staff records were reviewed to insure compliance.

Medications: Centrally stored medications were observed locked in a closet by the kitchen. Refills are either done automatically every 30 days, or ordered by the physician. At approximately 11:00 a.m medications and medication records were reviewed for proper documentation. Medication records are pre-filled by pharmacy and facility keeps a Medication Administration Record (MAR).

At approximately 11:40 a.m. LPA conducted interviews with client present and staff present during today's visit. Three (3) clients where not in the facility.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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