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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610449
Report Date: 10/25/2023
Date Signed: 08/15/2024 08:11:13 AM

Document Has Been Signed on 08/15/2024 08:11 AM - 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:EXCELLENCE COMMUNITY RESIDENTIAL PROPERTIES 2FACILITY NUMBER:
197610449
ADMINISTRATOR:ASKEW, OCTAVIAFACILITY TYPE:
735
ADDRESS:4369 PORTOLA DRTELEPHONE:
(424) 789-0439
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 0DATE:
10/25/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Octavia AskewTIME COMPLETED:
11:30 AM
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On 10/25/2023, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced pre-licensing visit to this facility and met with the Licensee. This is a new application and a fire clearance dated 08/03/2023 was received for six (6) ambulatory clients. The facility phone number is 661-579-6514.

The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Component III was conducted with the applicant from 9:15 am until 9:45 am

Today’s site visit consisted of LPA touring the physical plant inside and outside from 9:45 am until 10:15 am. LPA Spaeth observed the following:

Living Room/Dining Room – The living room and dining room are combined. The living room section contained comfortable seating. The dining room area contained a dining room table with dining room chairs.

Kitchen - The facility contained a seven-day supply of non-perishable food and a two-day supply of perishable foods. A fire extinguisher is located in the kitchen. Appliances in the kitchen appeared to be functional. The water temperature was recorded at 10:10 am and was 120.0 degrees F.

Backyard - The backyard contained an umbrella for shade and comfortable seating. The side gate leading from the backyard to the front yard was not locked. A storage shed is located in the backyard and was empty.

Continued - 809C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EXCELLENCE COMMUNITY RESIDENTIAL PROPERTIES 2
FACILITY NUMBER: 197610449
VISIT DATE: 10/25/2023
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Bedrooms - There are three (3) bedrooms which contained two (2) twin size beds, a mattress in each bed, linens, night stand, lamp, two chairs, chest of drawers, and a closet.

Bathrooms- There are two bathrooms which contained hand soap, paper towels, and trash can. Resident hygiene items were stored in the bathrooms.

Hallway - The hallway cabinet contained clean linens.

Laundry Room – the laundry room contained the washer and dryer.

Garage- LPA observed two locked cabinets which contained storage for the residents’ medications, a first aid kit, PPE supplies, knives, laundry detergent and cleaning supplies.

The smoke/carbon monoxide detectors were tested at 10:05 am and were operable. The facility was clean and appears to be in good repair.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Licensee. A copy of this report was signed and delivered.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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