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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610285
Report Date: 10/13/2022
Date Signed: 10/13/2022 01:39:55 PM

Document Has Been Signed on 10/13/2022 01:39 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:AKHILE ASSURANCE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197610285
ADMINISTRATOR:AKHILE, MYCOLFACILITY TYPE:
735
ADDRESS:43712 OLEANDER STREETTELEPHONE:
(714) 902-3571
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
10/13/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mycol Akhile, AdministratorTIME COMPLETED:
01:50 PM
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LPA arrived to the facility for the scheduled pre-licensing and Comp III visit. Upon entering the facility, LPA observed COVID signs on the front door and was asked the required COVID questions.

LPA conducted the Comp III presentation and the facility tour began at 11:30 am.

Common Areas: The facility maintains a comfortable temperature of 78 degrees F. LPA observed a living room contains comfortable seating along with a dining room table and a fireplace is appropriately gated.

Kitchen: LPA toured the kitchen and observed two-day supply of perishable food item such as fresh fruits, vegetables, and dairy products in the refrigerator. The freezer section contained frozen meats. The pantry contained a seven-day supply of canned goods. Medications will be stored in a kitchen cabinet and kept locked. First Aid Kit is readily available. LPA also observed all knives and sharp objects, in a drawer, kept locked and inaccessible to clients in care. The fire extinguisher is located by the kitchen.

Bedrooms: The first bedroom, by the entrance, is designated for live-in staff. All three bedrooms in the facility contained a bed, linens, night stand, night lamp, chest of drawers, and a closet. Extra linens are stored in a hallway closet.

Bathroom: LPA observed all bathrooms are clean and in good repair. Properly supplied with a toilet paper, soap and a paper towels. At 11:55 am, LPA recorded the hot water temperature which was 120 degrees F.

Garage: Laundry area is located in a garage. However, the washer and dryer will be purchased on 10/13/22 and the applicant will submit a receipt as a proof of purchase.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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: AKHILE ASSURANCE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197610285
VISIT DATE: 10/13/2022
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Outside area: LPA observed comfortable seating in the backyard and the side gate leading to the front yard. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

Smoke detector/carbon monoxide. The smoke detectors were located throughout the facility and the carbon monoxide was located in a hallway by the bathroom. At 12:10pm, they were tested and observed to be operational.

Facility is in compliance with Title 22 Regulations at this time. However, License approval pending prove that Washer and Dryer had been purchased. Once the proof of purchase received by LPA, this report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.



Exit interview conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2