197610373-2-24-2023-31-AS-MSPH-CPCRE8-20230224115708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610373
Report Date: 02/24/2023
Date Signed: 02/24/2023 11:57:16 AM

Document Has Been Signed on 02/24/2023 11:57 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:	WESTCLIFF RESIDENTIAL CARE		FACILITY NUMBER:	197610373
ADMINISTRATOR:	MANABAT, EILEEN		FACILITY TYPE:	740
ADDRESS:	39949 WESTCLIFF STREET		TELEPHONE:	(562) 377-4231
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 0	DATE:	02/24/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Eileen Manabat & Hazel Dimasuay		TIME COMPLETED:	12:00 PM

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On 2/24/2023, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with applicants Eileen Manabat and Hazel Dimasuay. This is an initial application for an adult residential care facility. A fire clearance dated 12/21/2022 was received for six (6) bedridden residents. 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 9:20 am until 10:20 am with applicants.
Today’s site visit consisted of LPA touring the physical plant inside and outside with the applicants from 10:25 am until 10:55 am. LPA observed the following:

Facility has a functional fire extinguisher. There is a functioning telephone on the premises. The facility phone number 661-526-3128. Emergency exit plan/sketch is posted on the living room wall and the family room wall along with other posting requirements. The smoke detectors were checked at 10:45 am and was functional. The carbon monoxide detectors were also functional. The doors leading from inside to the outside contained functional egress alarms.

There are five (5) resident bedrooms (four (4) single bedrooms and one double occupancy bedroom). LPA observed bed linens, chest of drawers, closet, night stand, and lamp in each bedroom. The bedrooms were neat and clean.

The facility office contained a desk and a bed for the live-in staff. There is an additional staff bedroom/bathroom and the staff files are locked in the staff bedroom.

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

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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: WESTCLIFF RESIDENTIAL CARE	FACILITY NUMBER: 197610373
	VISIT DATE: 02/24/2023

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Resident records and medications are stored in a locked hallway closet along with PPE supplies and the first aid kit. LPA observed the locked laundry room which contained laundry soap and additional linens stored in a cabinet. The garage contained emergency food supply and water.

There are two (2) bathrooms in the facility. The two (2) bathrooms contained non-skid mats, grab bars, hand soap, and trash can with tight fitting lids. At 10:25 am, the water temperature was tested and noted to be 107.8 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 and cleaning solutions are safely locked underneath the kitchen sink. Appliances in the kitchen appeared to be functional.

The backyard is furnished with a shaded area and comfortable seating. The side gates leading from the backyard to the front yard were not locked.

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 applicants. A copy of this report was signed and delivered.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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