197610396-4-5-2023-31-AS-MSPH-CQLW3N-20230405165614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610396
Report Date: 04/05/2023
Date Signed: 04/05/2023 04:56:19 PM

Document Has Been Signed on 04/05/2023 04:56 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HUMBLE HAVEN RCFE V		FACILITY NUMBER:	197610396
ADMINISTRATOR:	DE LAS ALAS, NICOLE		FACILITY TYPE:	740
ADDRESS:	5542 LAS BRISAS TERRACE		TELEPHONE:	(707) 688-5606
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 6		CENSUS: 0	DATE:	04/05/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nicole De Las Alas		TIME COMPLETED:	11:30 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 4/05/2023, Licensing Program Analysts (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with Nicole De Las Alas. This is a new application and a fire clearance dated 1/16/2023 was received for five (5) non-ambulatory and one (1) bedridden resident. 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 9:15 am until 9:50 am. Today’s site visit consisted of LPA touring the physical plant inside and outside from 9:50 am until 10:25 am and observed the following: LPA observed comfortable seating in the living room and family room. The dining room contained table and chairs. Fresh fruit was available for residents on the dining room table. The family room contained a television and games. The kitchen contained a seven-day supply of non-perishable food and a two-day supply of perishable foods. A locked kitchen cabinet underneath the kitchen sink contained the cleaning supplies. There is a designated locked cabinet for resident medications and for the knives. A fire extinguisher was located in the kitchen. Appliances in the kitchen appeared to be functional. The backyard contained comfortable seating for residents. The side gate leading from the backyard to the front yard was not locked.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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: HUMBLE HAVEN RCFE V	FACILITY NUMBER: 197610396
	VISIT DATE: 04/05/2023

NARRATIVE

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There are four bedrooms which contained bed, linens, night stand, lamp, chest of drawers, chairs and a closet. The rooms were neat and clean.

There are three bathrooms which contained hand soap, paper towels, trash can, grab bars, and slip resistant mats. The water temperature was recorded at 10:02 am and was 111.0 F.

The door leading to the garage was locked and LPA did not observe any health or safety issues when viewing the garage. There are two hallway closets which contained linens, hygiene items, and additional PPE. The laundry room was locked and LPA observed the laundry detergent was locked in a cabinet.

The smoke and carbon monoxide detectors were tested at 10:10 am. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all exit doors. 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: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC809 (FAS) - (06/04)

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