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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610434
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:59:48 PM

Document Has Been Signed on 10/19/2023 04:59 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 INCFACILITY NUMBER:
197610434
ADMINISTRATOR:LEE, DYNTAIEFACILITY TYPE:
735
ADDRESS:738 TRIXIS AVETELEPHONE:
(661) 492-6769
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: 0DATE:
10/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:58 PM
MET WITH:Dyntaie LeeTIME COMPLETED:
05:10 PM
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At 3:45 pm Licensing Program Analyst (LPA) Tihesha Smith made a subsequent visit to this facility for Pre-licensing visit.

LPA Smith conducted initial pre-licensing visit on 10/05/2023 at approximately 10:00 AM. 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

During today’s visit LPA observed the following:

· microwave repaired and functional

· smoke detector installed in kitchen

(Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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: 10/19/2023
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(Cont 809C)

chest of drawers and nightstands in each room are in good repair

· lamps are in each room

· televisions are in each room

· personal items stored in garage have been removed

· washing machine and dryer appliances have been cleaned and are functional

· walls and fixtures have been cleaned

· Garage door paint/repaired

ARF PowerPoint presentation conducted was conduction on 10/05/2023.

In general, the facility is clean, safe, and in good condition and ready to be licensed. The facility is in compliance with Title 22 regulations.

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: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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