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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610295
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:42:42 PM


Document Has Been Signed on 08/02/2024 03:42 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:1ST CARING TRADITIONSFACILITY NUMBER:
197610295
ADMINISTRATOR:MEDEL, REYFACILITY TYPE:
740
ADDRESS:3234 TOURNAMENT DRIVETELEPHONE:
(661) 441-0023
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 6DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mike Retuya and Hope VargasTIME COMPLETED:
02:30 PM
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On 08/07/2023 at 1:30 pm, Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced required annual visit. LPA Melissa Spaeth was greeted by the two caregivers. The facility is licensed as a Residential Care Facility for the Elderly (RCFE) to serve six residents of which five (5) may be non-ambulatory and one (1) may be bedridden. There is a hospice waiver for six residents. The facility currently has six residents. LPA spoke to the Administrator Rey Medel who stated the caregiver can sign the report for LPA Spaeth

LPA and caregiver began the tour at 12:10 pm until 12:50 pm

Common areas – LPA observed the living room and family room contain comfortable seating.

Dining Room/Kitchen Combination – LPA observed a seven-day supply of non-perishable food and a two-day supply of perishable food in the refrigerator. The kitchen knives were locked in a kitchen cabinet. The resident medications are locked in a kitchen cabinet along with the first aid kit. The cleaning solutions were locked underneath the kitchen sink. The fire extinguisher is located in the kitchen area.

Backyard- LPA observed comfortable seating located in a shaded area. The gate leading from the backyard to the front yard was not locked.

Resident Bedrooms – LPA observed the rooms were neat and clean. The bedrooms contained bed, linens, night stand, night lamp, and closet.

Bathrooms – Both bathrooms contained hand soap, paper towels, trash can, slip resistant mat, and grab bars. The water temperature was tested at 12:30 pm and was 109.7 degrees F.

Hallway Closet – This closet contained PPE supplies and linens were also located in a hallway closet.

Continued on 809-C

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
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: 1ST CARING TRADITIONS
FACILITY NUMBER: 197610295
VISIT DATE: 08/02/2024
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Laundry Room – The laundry room was locked and the laundry detergent, hygiene items, and additional cleaning solutions were located in the laundry cabinet.

Garage – The door leading to the garage was locked. LPA observed an additional refrigerator/freezer which contained additional food for the facility.

Smoke/Carbon Monoxide Detector- The detectors were tested at 1:45 pm and were functional.

LPA reviewed the residents’ files at 1:00 pm until 1:30 pm. LPA reviewed staff files at 1:30 pm until 1:55 pm. LPA also viewed the resident's medication at 1:55 pm until 2:15 pm

There are no deficiencies to report at this time. Exit interview conducted and a copy of the report was given to the Administrator.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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