197610299-10-18-2023-31-AS-ADUA-CWQVHY-20231018162754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610299
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:28:25 PM

Document Has Been Signed on 10/18/2023 04:28 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:	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: 4	DATE:	10/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Ruskie Ragasa, Administrator		TIME COMPLETED:	04:35 PM

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced annual inspection visit at around 9:30 AM and met with Administrator Ruskie Ragasa. At the time of this visit LPA Duguma observed two (02) additional individuals working in the facility. LPA Duguma also observed and assessed four (04) 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. This is a single-story property. The facility is fire cleared for six (06) non-ambulatory of which one (01) maybe bedridden and has a hospice waiver for six (06). The facility has a total of five (05) bedrooms, of which four (04) 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 115.8ºF 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. Smoke 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 01/06/2023.

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.

(CONT on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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: 10/18/2023

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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.

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: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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