197610348-1-11-2024-31-AS-MSPH-CZDULZ-20240111144130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610348
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:41:38 PM

Document Has Been Signed on 01/11/2024 02:41 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:	CLUB RANCHO MANOR INC		FACILITY NUMBER:	197610348
ADMINISTRATOR:	DE LIMA, MARY ANN		FACILITY TYPE:	740
ADDRESS:	3618 CLUB RANCHO DRIVE		TELEPHONE:	(323) 680-0844
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 5	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mary Ann De Lima		TIME COMPLETED:	01:50 PM

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregivers and greeted by the Administrator who arrived at 10:35 am. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are five residents.. The facility is licensed for a total of six non-ambulatory residents of which two can be bedridden.

LPA Spaeth and the Administrator toured the location at 10:50 am until 11:24 am.

Common Areas – LPA observed the family room, kitchen, and dining room are combined. The family room contained comfortable seating and a television. The dining room section contained a dining room table and chairs.

Kitchen – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food items. The medications are locked in a kitchen cabinet. The knives were locked in a kitchen drawer. A fire extinguisher was located in the kitchen area.

Laundry Room – The laundry room was located and contained washer/dryer, laundry soap, and cleaning solutions.

Hallway – The hallway contained cabinets and the clean linens are stored in the cabinet..

Garage - LPA observed the garage was locked. An additional freezer is located in the garage and contained additional frozen food items.

Resident Bedrooms - There are four resident bedrooms which are furnished with a bed, linens, night stand, chest of drawers and a closet. Two residents are currently in the master bedroom (Bedroom #3) along with the master bath.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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: CLUB RANCHO MANOR INC	FACILITY NUMBER: 197610348
	VISIT DATE: 01/11/2024

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Bathrooms – There are two bathrooms in the facility which contained hand soap, paper towels, slip resistant mat, and a trash can. LPA tested the water temperature at 11:00 am which was 117.0 degrees F.

Backyard - Comfortable outdoor seating is provided for the residents. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The detectors were tested at 11:10 am and were operable.

LPA reviewed residents' records at 11:51 am until 12:15 pm. LPA reviewed staff records at 12:15 pm until 12:40 pm LPA reviewed resident medications at 1:00 pm until 1:15 pm.

There are no deficiencies to report. The exit interview was conducted, and a copy of the signed report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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