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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610361
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:35:55 PM

Document Has Been Signed on 08/29/2024 03:35 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 FACILITYFACILITY NUMBER:
197610361
ADMINISTRATOR/
DIRECTOR:		TILLMAN, WILDA WFACILITY TYPE:
735
ADDRESS:3330 RACQUET LANETELEPHONE:
(661) 916-9090
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Jeanette GonzalezTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 8/29/2024, Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual inspection and met by the Administrator. The Administrator confirmed there are four residents living in the facility.
LPA Spaeth conducted a tour and 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 were 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.

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 a bed, linens, night stand, lamp, chest of drawers, a chair and a closet.


Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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: LIBERTY RESIDENTIAL FACILITY
FACILITY NUMBER: 197610361
VISIT DATE: 08/29/2024
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Bathrooms- There are three bathrooms which contained hand soap, paper towels, and trash can. The water temperature was recorded at 2:30 pm and was 120.0 degrees F.

Hallway - The hallway cabinet contained clean linens.

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

LPA Spaeth reviewed the client records and the staff records at 1:30 pm until 2:00 pm.

Smoke and Carbon Monoxide Detectors - The detectors were checked at 2:40 pm and were operable.

There are no deficiencies to report at this time. Exit interview was conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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