197610413-9-12-2023-31-AS-MCAA-CVLQTM-20230912122722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610413
Report Date: 09/12/2023
Date Signed: 09/12/2023 12:27:31 PM

Document Has Been Signed on 09/12/2023 12:27 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:	SUMMERSET ARF		FACILITY NUMBER:	197610413
ADMINISTRATOR:	MUNOZ, ANDERSON B		FACILITY TYPE:	735
ADDRESS:	1559 ROYWOOD DR		TELEPHONE:	(818) 687-3830
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS: 0	DATE:	09/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anderson Munoz, Christine Munoz, Dexter Munoz		TIME COMPLETED:	12:30 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 Analysts (LPAs) Lorena Casillas and Michael Cava along with Licensing Program Manager (LPM) Nichelle Gillyard, conducted a Pre-Licensing Inspection with the applicant representative and administrator, Anderson Munoz and staff Christine and Dexter Munoz. An Application to operate an Adult Residential Facility (ARF)) was received by Community Care Licensing (CCL) on February 13, 2023. Facility will be vendorized by North Los Angeles Regional Center (NLARC) level 4i. A fire clearance was approved on June 6, 2023 for four (4) non-ambulatory residents for a total capacity of four. The smoke alarms are hard wired and inter-connected. The carbon monoxide detector is functional and installed in the hallway. The facility has one fire extinguishers that was fully charged June 5, 2023. It is located by the dining room, living room area. In addition to the Pre-Licensing, a Component III was held. A tour of the physical plant was initiated at approximately 10:00am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. The hot water delivered is measured at 119 degrees F. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of four (4). Knives will be locked in a kitchen drawer. BEDROOMS: There are four (4) bedrooms designated for resident use. All four rooms are designated to be private rooms. Bedrooms #2 has a direct exit. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. Bedrooms #2 to #4 have sufficient closet space. Applicant has ordered a cabinet for bedroom #1. All rooms had sufficient lighting. BATHROOMS: The facility has two (2) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid mats. The hot water delivered in the bathrooms measured at 120 degrees.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUMMERSET ARF	FACILITY NUMBER: 197610413
	VISIT DATE: 09/12/2023

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

COMMON AREAS: These included the living room and dining room areas, which were equipped with living room furniture, a television, tables and chairs. The dining room table is large enough to accommodate up to six (6) . There is a fireplace with a screen and a glass slide. It is non-operational. No fireplace tools or fixtures present. There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located adjacent to the kitchen. The applicant will install a locked cabinet to store detergent and cleaning supplies.

MEDICATIONS: Medications will be stored in a locked cabinet in the kitchen.

STAFF/RESIDENT RECORDS: Staff and resident records will be stored in a locked cabinet, located by the dining area. The applicant was advised to insure that resident and staff records will be accessible the licensing agency upon request or during inspection. Facility will have awake staff.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. Entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture. The facility backyard has sufficient yard space to accommodate outdoor activities. There is no swimming pool or bodies of water.
Prior to licensure, the applicant needs to provide the following:

Facility sketch with dimensions and include shut off valves.
Obtain a larger LTCO and Personal Rights poster
Install a sensor for the exit door in room #2
Larger chest drawers
Closet/cabinet for client bedroom #1
Trash cans in bathrooms require lids.
Repair hole in closet door

The applicant was advised and will submit corrections within ten days. A copy of this report given.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2