197610434-10-5-2023-31-AS-TSMH-CWBTYH-20231005150847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610434
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:08:53 PM

Document Has Been Signed on 10/05/2023 03:08 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:	DESERT BREEZE ADULT CARE FACILITY INC		FACILITY NUMBER:	197610434
ADMINISTRATOR:	LEE, DYNTAIE		FACILITY TYPE:	735
ADDRESS:	738 TRIXIS AVE		TELEPHONE:	(661) 492-6769
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY: 4		CENSUS: 0	DATE:	10/05/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Dyntaie Lee		TIME COMPLETED:	03:15 PM

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At approximately 10:00 am Licensing Program Analyst (LPA) Tihesha Smith conducted an announced pre-licensing visit with administrator. Identification of the Applicant/administrator was verified by CA Driver’s License.
The facility has a capacity of four (4). Application received for four (4) Ambulatory residents.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

Today's site visit consisted of LPA Smith touring the physical plant inside and outside and observed the following:

The common areas (kitchen, living room, and dining areas) were appropriately furnished, and lighting was adequate. The facility contained a seven-day supply of non-perishable food and a two-day supply of perishable foods.

LPA observed the living room and dining room are combined. The living room area contained a large sectional sofa with sufficient seating for residents, a coffee table, and television. The dining room contained a dining room table and four (4) chairs.

There are 4 (four) bedrooms. Bedroom # 1 has bed, linens, television,nightstand, lamp, chest of drawers, a chair and a closet available. All other rooms are not completely furnished and furniture observed to be damaged in one or more rooms.

The linen is stored at end of hallway in cabinets that was fully stocked with clean linen.

There are two (2) bathrooms which contained hand soap, paper towels, trash can, and slip resistant mats. The water temperature was recorded at 2:05 pm and was at: 111.7- and 112.0-degrees F.

(Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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: DESERT BREEZE ADULT CARE FACILITY INC	FACILITY NUMBER: 197610434
	VISIT DATE: 10/05/2023

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(Cont. from 809)

The medications, first aid kits, staff and resident files are stored and locked in hall closet. There are two cabinets inside the locked closet (two-drawer cabinet and a three-drawer cabinet.) There is also a lockbox in the closet to store the sharps.

The garage was locked, and LPA Smith observed the washer and dryer located in this area along with personal items. The toxins will be stored in locked garage.

The backyard contained: Patio set with four (4) chairs, table, and umbrella.

Component III was conducted with the applicant from 12:25 p.m.- 1:10 pm.

At time of visit this facility is not ready to be licensed. The following corrections must be made:

· Repair and clean microwave

· Have smoke detector installed in kitchen

· Provide undamaged (furniture) chest of drawers and nightstands for each room

· Provide lamps for each room

· Remove or add televisions to each room

· Remove personal items stored in garage

· Clean washing machine and dryer appliances

· Clean walls and fixtures

· Repair garage door/Peeled off paint

This report will be forwarded to the Centralized Application Bureau (CAB).

Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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