197610299-7-19-2022-31-AS-ADUA-CGGLDP-20220719084016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610299
Report Date: 07/19/2022
Date Signed: 07/19/2022 08:41:02 AM

Document Has Been Signed on 07/19/2022 08:41 AM - 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:	ALAMINOS HOME		FACILITY NUMBER:	197610299
ADMINISTRATOR:	RAGASA, RUSKIE		FACILITY TYPE:	740
ADDRESS:	21514 ALAMINOS DRIVE		TELEPHONE:	(661) 993-4362
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91350
CAPACITY:	6	CENSUS: 5	DATE:	07/19/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ruskie Ragasa		TIME COMPLETED:	08:31 AM

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	Licensing Program Analyst (LPA) Abeye Duguma conducted an announced Pre-licensing visit at 2:20 PM and met with Administrator Ruskie Ragasa. This is a change of ownership application from D’Elders “R” US (197606449) to Alaminos Home Inc (197610299). LPA conducted an entrance interview with the Administrator. At the time of this visit LPA Duguma observed three (03) additional individuals working in the facility. LPA Duguma also observed and assessed five (05) residents present in the facility. All residents appear to be clean and well groomed. With the assistance of the Administrator, LPA conducted a facility tour of both the inside and outside. The facility was inspected for Fire Safety, Personal Accommodations and Services, Medication Procedures and Food Service. This is a single-story property. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for one (01). The facility has a total of six (06) bedrooms, of which five (05) are for residents and one (01) is for staff. The facility has two (02) bathrooms for both residents and staff. Residents bathroom has properly installed grab bars and shower has non-skid mats. Hot water temperature measured at 118.3ºF during the visit. All residents’ bedrooms were adequately furnished. The common areas were appropriately furnished. The LPA observed entertainment equipment and games for activities. The resident and staff records were stored in a file cabinet located near the dining area. The first-aid kit is complete. The linens were stored in the storage space located in the hallway. LPA observed a fireplace that was blocked with a screen. The facility has working alarms on all exits. Smoke detectors and Carbon Monoxide detectors were checked and function properly. There is one (01) fully charged fire extinguisher located in the kitchen area. Fire extinguisher was certified on 01/07/2022. (cont. on 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALAMINOS HOME	FACILITY NUMBER: 197610299
	VISIT DATE: 07/19/2022

NARRATIVE

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LPA Duguma observed a washer and dryer in the garage. All chemicals, additional personal hygiene items were stored in a locked storage closet near the front entrance.

LPA inspected the kitchen and observed stove and refrigerator to be clean and working. Facility had sufficient quantity and variety of perishable and nonperishable food supply. Nonperishable food was stored in a pantry. The medications are stored in a locked cabinet located near the front entrance. Sharps are stored in a locked kitchen drawer.

There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. The facility has a swimming pool/body of water which is gated and locked.

At the time of this visit the physical plant is meeting Title 22 requirements.

The Component III is waived as the Administrator attended a component III meeting on 06/28/2022.

No health and safety hazard were noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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