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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610413
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:36:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/22/2025 12:36 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUMMERSET ARFFACILITY NUMBER:
197610413
ADMINISTRATOR/
DIRECTOR:		MUNOZ, ANDERSON BFACILITY TYPE:
735
ADDRESS:1559 ROYWOOD DRTELEPHONE:
(818) 687-3830
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Anderson MunozTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lorena Casillas met with administrator Anderson Munoz for an unannounced one (1) year Required visit for this facility.

LPA arrived at 09:30 am and was greeted by Administrator. LPA explained the reason for the visit and an entrance interview was conducted.

A tour of the physical plant was conducted with the Administrator at 09:45 am and the following was observed:

The facility does not currently have any clients as they are still waiting on approval of vendorization from North Los Angeles Regional Center. Tool Kit will not be used during this inspection as there are no clients in the home.

Infection Control: LPA Casillas reviewed facility infection control plan received on 05/24/23 to make sure licensee was following current infection control recommendations.

Kitchen: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. The hot water delivered is measured at 110.1° F. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of four (4). Perishable food will be purchased once there are clients in the facility. Knives will be locked in a kitchen drawer and inaccessible to clients in care.

Bedrooms: There are four (4) bedrooms designated for client use. All four rooms are designated to be private rooms. Bedroom #2 has a direct exit. Client bedrooms have beds, nightstand, chairs, dresser, bedding and linen. All rooms have sufficient lighting.
Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUMMERSET ARF
FACILITY NUMBER: 197610413
VISIT DATE: 01/22/2025
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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 110.3° F.

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 all clients. There is a fireplace with a screen and a glass slide cover. The fireplace is non-operational. The smoke alarms are hard wired and were tested at 11:00 am along with the carbon monoxide detector and were functional. The facility has one fire extinguishers that was fully charged and is located by the dining room area.



Laundry Room: The laundry room is located adjacent to the kitchen, it is locked and inaccessible to clients.

Physical Environment: The driveway, passageways and entrance to the home are 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.

Garage: At 11:15 am, LPA observed the garage to be attached to the facility and currently being used for an extra storage and PPE supplies.



Staff & Client Records: Staff and resident records will be stored in a locked cabinet, located by the dining area. The Administrator was reminded to ensure that resident and staff records will be accessible the licensing agency upon request or during inspection.

Administrative: Annual fee is current. Administrator certificate was emailed to LPA.

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



Staff & Client Interviews: There are no clients or staff to interview.

An exit interview was conducted, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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