197610360-2-10-2023-31-AS-MSPH-CNWRDX-20230210115639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610360
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:56:46 AM

Document Has Been Signed on 02/10/2023 11:56 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:	BUENAVISTA LIVING WELL CENTER		FACILITY NUMBER:	197610360
ADMINISTRATOR:	ENOLA, JAMELENE JOY S.		FACILITY TYPE:	735
ADDRESS:	1106 WEST AVENUE O		TELEPHONE:	(253) 353-0587
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 6		CENSUS:	DATE:	02/10/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jamelena Joy S. Enola & Jean Sevilla		TIME COMPLETED:	12:00 PM

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On 2/10/2023, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with applicants Jamelena Joy S. Enola & Jean Sevilla. This is an initial application for an adult residential care facility. A fire Clearance dated 12/29/2022 was received for six (6) residents, of which four (4) could be non-ambulatory residents, and two could be ambulatory. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 9:10 am until 10:00 am with applicants.

Today’s site visit consisted of LPA touring the physical plant inside and outside with the applicants from 10:00 am until 10:55 am. LPA observed the following:

Facility has a fire extinguisher, with a date of purchase of 10/03/2022. There is a functioning telephone on the premises. The facility phone number 661-526-5959. Emergency exit plan/sketch is posted on the living room wall with other posting requirements. The smoke/carbon monoxide detectors were checked at 10;55 am and were functional.

There are (4) resident bedrooms (two single bed rooms and two double bed rooms). LPA observed bed linens, chest of drawers, closet, night stand, and lamp in each bedroom. The bedrooms were neat and clean.

The common areas (living room, kitchen and dining areas) were appropriately furnished, and lighting was adequate. The living room was furnished with games, comfortable seating and a television.

Resident and staff records are stored in a locked hallway cabinet. LPA observed a linen closet which contains towels, bed linens, and blankets.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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: BUENAVISTA LIVING WELL CENTER	FACILITY NUMBER: 197610360
	VISIT DATE: 02/10/2023

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There are three (3) bathrooms in the facility. The three bathrooms contained non-skid mats, grab bars in Bathroom 2, hand soap, and trash can with tight fitting lids. Bathroom 2 is the designated bathroom for non-ambulatory residents. At 10:15 am, the water temperature was tested and noted to be 114.0 F.

LPA observed a seven-day supply of perishable food items and a two-day supply of non-perishable food items in the kitchen. The kitchen knives are stored in a locked kitchen cabinet. The liquid soap is safely locked underneath the kitchen sink. Appliances in the kitchen appeared to be functional. Medications and first aid kit are stored in a locked kitchen cabinet.

The laundry detergent and cleaning solutions are locked in the laundry room. The laundry room leads to the garage. LPA observed PPE supplies and emergency food and water supplies.

LPA observed the facility property is surrounded by a fence but the exit gate which is located at the front of the property was not locked. The backyard is spacious with a covered area which contained chairs and tables. LPA observed the staff quarters is located in a detached building beside the facility. LPA observed a three-quarter wall which separates the facility sitting area and the back of the property. The back area past the wall contains an open garage but LPA did not observe any known hazards within that area.

LPA observed construction materials beside the detached staff living quarters. The applicants stated renovation projects were completed but applicants are waiting for a locked storage unit to be installed on the property. A detached storage unit will be installed this weekend, 2/12/2023. LPA scheduled an additional visit for Friday, February 17, 2023 at 9:00 am to observe the items were moved to the storage unit.

Exit interview was conducted and a copy of this report was signed and given to applicants.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC809 (FAS) - (06/04)

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