197610361-9-20-2023-31-AS-MSPH-CVURWA-20230920132247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610361
Report Date: 09/20/2023
Date Signed: 09/20/2023 01:22:53 PM

Document Has Been Signed on 09/20/2023 01:22 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:	LIBERTY RESIDENTIAL FACILITY		FACILITY NUMBER:	197610361
ADMINISTRATOR:	TILLMAN, WILDA W		FACILITY TYPE:	735
ADDRESS:	3330 RACQUET LANE		TELEPHONE:	(661) 916-9090
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 4		CENSUS: 0	DATE:	09/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Wilda Tillman		TIME COMPLETED:	11:00 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	On 9/20/2023, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with the Licensee. This is a new application and a fire clearance dated 05/23/2023 was received for four (4) ambulatory residents. The facility phone number is 661-526-4923. 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. Component III was conducted with the applicant from 9:40 am until 10:11 am Today’s site visit consisted of LPA touring the physical plant inside and outside from 9:10 am until 9:40 am. LPA Spaeth observed the following: Living Room – The room contained comfortable seating. Kitchen/Dining Room - The facility contained a seven-day supply of non-perishable food and a two-day supply of perishable foods. The kitchen closet was locked and contained the knives, first aid kit, and emergency food and water. The clients’ medications will be locked in a kitchen cabinet. Cleaning supplies were also locked in a kitchen cabinet. A fire extinguisher is also located in the kitchen. Appliances in the kitchen appeared to be functional. The dining room area contained a dining room table with chairs and games. The water temperature was recorded at 9:20 am and was 115.0 degrees F. Living/Dining Room – LPA observed the living room and dining room are combined. The living room area contained two couches, chairs, and a television. The dining room contained a dining room table with chairs. A locked cabinet contained cleaning solutions and laundry soap. Continued - 809C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LIBERTY RESIDENTIAL FACILITY	FACILITY NUMBER: 197610361
	VISIT DATE: 09/20/2023

NARRATIVE

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Backyard - The backyard contained a shaded area with comfortable seating. The side gate leading from the backyard to the front yard was not locked.

Bedrooms - There are four bedrooms which contained bed, linens, night stand, lamp, chest of drawers, a chair and a closet.

Bathrooms- There are three bathrooms which contained hand soap, paper towels, and trash can.

Hallway - The hallway cabinet contained clean linens.

Laundry Room – the laundry room contained the washer and dryer.

Garage- LPA observed an additional freezer which contained frozen meats.

The smoke and carbon monoxide detectors were tested at 10:05 am and were operable. The facility was clean and appears to be in good repair.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Licensee. A copy of this report was signed and delivered.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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