197610373-1-18-2024-31-AS-MSPH-CZLVL8-20240118153127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610373
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:31:40 PM

Document Has Been Signed on 01/18/2024 03:31 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:	WESTCLIFF RESIDENTIAL CARE		FACILITY NUMBER:	197610373
ADMINISTRATOR:	MANABAT, EILEEN		FACILITY TYPE:	740
ADDRESS:	39949 WESTCLIFF STREET		TELEPHONE:	(626) 487-5691
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 1	DATE:	01/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Eileen Manabat & Hazel Dimasuay		TIME COMPLETED:	12:45 PM

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

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrators. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrators confirmed there is one resident. The facility is licensed for a total of six bedridden/hospice residents.

LPA Spaeth and the Administrator toured the location at 10:00 am until 10:30 am.

Common Areas – The living room was furnished with comfortable seating. 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 knives were locked in a kitchen drawer. The cleaning solutions were locked underneath the kitchen sink.

Hallway – The hallway contained a locked closet which contained the resident file, resident medications, resident hygiene items, and the first aid kit on the top two shelves. Additional cleaning supplies were stored on the bottom of the closet

Laundry Room – The laundry room was locked and contained washer/dryer and laundry soap. A door leading to the garage was locked

Garage - LPA observed the garage was locked. The emergency food was stored in this location.

Continued on 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: WESTCLIFF RESIDENTIAL CARE	FACILITY NUMBER: 197610373
	VISIT DATE: 01/18/2024

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
26
27
28
29
30
31
32

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 10:15 am which was 109.3 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 smoke detectors and the carbon monoxide detectors were tested at 10:15 am and were operable.

LPA reviewed residents' records at 10:45 am until 11:15 am. LPA reviewed staff records at 11:45 am until 12:00 pm. LPA reviewed resident medications at 12:25 pm until 12:35 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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2