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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610434
Report Date: 10/19/2024
Date Signed: 10/19/2024 12:02:31 PM

Document Has Been Signed on 10/19/2024 12:02 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DESERT BREEZE ADULT CARE FACILITY INCFACILITY NUMBER:
197610434
ADMINISTRATOR/
DIRECTOR:		LEE, DYNTAIEFACILITY TYPE:
735
ADDRESS:738 TRIXIS AVETELEPHONE:
(661) 492-6769
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: 0DATE:
10/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Sara Lewis TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with Sara Lewis, friend of the administrator Dyntaie Lee. Ms. Lewis called the administrator, purpose of the visit is stated. Administrator designated Ms. Lewis to sign the report. This will be a North Los Angeles Regional Center (NLARC) vendored facility Level IV-A., per the administrator.

LPA conducted physical plant tour inside and out at 9:38 AM. During the tour, LPA observed that the facility has four (4) bedrooms and two (2) bathrooms. There is no body of water in the facility.

The front main door is the only entrance being utilized at the facility. The facility had submitted and approved Mitigation and Infection Plan.

The facility has a designated visitors' area at the backyard.

Bedrooms: Two (2) of the bedrooms are unfurnished during this visit and the other two (2) have bed and being used by family members.
Bathrooms were observed to be relatively clean and with necessary supplies. Hot water temperature measured at a range of 111.2°F to 115.7°F.

Living and dining room furniture were also checked for functionality (wear and tear). Living area has sofa but there is no dining table and chairs.
Kitchen area is under construction and per the administrator, due to a leak, they have removed all the furniture at the facility.

(continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DESERT BREEZE ADULT CARE FACILITY INC
FACILITY NUMBER: 197610434
VISIT DATE: 10/19/2024
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(continued from LIC 809)

Food. There is no food at the facility at this time as the facility is non-operational.

Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.

Fire extinguisher was observed to be located in the bedroom hallway. There is carbon monoxide detector alarm installed in the facility.

Medication: No medication at this time.

Garage is attached to the facility. Garage is also used as a Laundry area and storage for old equipment.

Per the administrator, this facility is still waiting for the insurance to fix the damage to the house and will not be operational in a very near future as their vendorization is still far away on its process.

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

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC809 (FAS) - (06/04)
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