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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610250
Report Date: 05/06/2024
Date Signed: 05/06/2024 01:32:08 PM

Document Has Been Signed on 05/06/2024 01:32 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/
DIRECTOR:		AIDINOVA, SALBIFACILITY TYPE:
735
ADDRESS:2810 W AVENUE J12TELEPHONE:
(818) 383-1780
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 3DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Salbu Aidinova - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 05/06/2024 at 9:30 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection using the CARE Inspection Tool. This is an Adult Residential Facility (ARF), level 3 with an approved fire clearance for four (4) ambulatory clients. LPA was greeted by staff #1(S1) and staff #2 (S2) who granted access. S1 informed the administrator, LPA was at the facility. Administrator, Salbi Aidinova met LPA shortly after and LPA explained the reason for the visit.

At approximately 10:00 a.m. LPA and the administrator toured the physical plant of the facility, and the following was observed.

Kitchen/ Dinning areas: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable supply of food; properly stored. On one of the kitchen's walls, LPA observed one (1) fire extinguisher fully charged with purchased date, 06/11/2023. By one of the dinning walls LPA observed required facility postings. Dining areas had appropriate table and chairs to sit the capacity of the facility. LPA observed, first aid kits, client medications, facility files and knives kept locked in a closet by the kitchen. LPA observed the facility telephone on the kitchen counter, operational.
Garage: Garage is located by the kitchen accessible to clients and staff. LPA observed extra refrigerator with food and extra pantry food. LPA observed facility vehicle parked in the garage.
Living rooms: The facility has two (2) living areas. Both were observed clean and properly furnished. Two (2) fireplaces were observed closed and secured with screens. LPA observed a television and games for client use.
Laundry: Laundry room is located by the bedrooms. Detergents, extra cleaning supplies, and toiletries where observed locked in a closet by the laundry room. Washer and dryer were observed operational.
(Continued on to LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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 4
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: 05/06/2024
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(Continued LIC809-C)
Bathrooms: The facility has three (3) total bathrooms one (1) of which is in the staff bedroom for staff use. The LPA took hot water temperature from one (1) out two (2) client bathrooms and temperature read between 107 degrees Fahrenheit and 118 degrees Fahrenheit, within regulation. LPA observed both bathrooms to be clean and properly supplied with toilet paper, hand soap, paper towels and trash bins with lids.
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.

At 10:20 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 that is connected to the smoke detectors through out the facility.

Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for clients to use.
Facility Records: Records reviewed include facility, staff and clients records. At approximately 10:25 a.m. three (3) out three (3) client records and (2) staff records were reviewed to insure compliance.
Medications: Centrally stored medications were observed locked in a closet by the kitchen. At approximately 11:42 a.m medications and medication records were reviewed for proper documentation. Centrally Stored Medication Records are pre-filled by pharmacy and facility keeps a Medication Administration Record (MAR).

At approximately 12:40 p.m. LPA conducted interviews with two staff present during today's visit. Three (3) of 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: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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