197610453-9-6-2023-31-AS-AALR-CVESM7-20230906135929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610453
Report Date: 09/06/2023
Date Signed: 09/06/2023 01:59:34 PM

Document Has Been Signed on 09/06/2023 01:59 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ASAGAO HOME CARE		FACILITY NUMBER:	197610453
ADMINISTRATOR:	MAKINOSE, ANNE LOUISE		FACILITY TYPE:	740
ADDRESS:	45701 17TH ST. W		TELEPHONE:	(213) 294-8188
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	6	CENSUS: 3	DATE:	09/06/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:			TIME COMPLETED:	02:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Antonia Alvizar met with Anne Louise Makinose, to conduct the pre-licensing inspection for Asagao Home Care Facility. An application for a total of six (6) non-ambulatory residents over the age of sixty (60), which of one (1) may be bedridden in room #1, Hospice Waiver approved for three (3) residents was submitted for, residents located at, 45701 17^th Street West, Lancaster, CA 93534. A fire clearance was approved for the above noted residence location. There is a dementia care plan.

At 11:55AM LPA Alvizar conducted a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards. The facility is a single story five (5) bedroom family home, with two (2) bathrooms, with one (1) room used for staff; that is adjacent to a family room and television. Bathrooms had nonskid -material in bathtubs, and grabs bar by toilet and shower. Water temperature measured at 115.5 and 118.5 degrees Fahrenheit within regulation. All resident bedrooms observed had the required furniture for residents’ comfort and safety. Common areas were appropriately furnished, and lighting is adequate. The family room had activities available for residents. Resident and staff records are stored in a locked file cabinet. Sharp tools, kitchen knives, chemicals, toxins, cleaning supplies, and personal hygiene products are locked and secured, and located in various areas of the facility: kitchen and garage area.

The supply of dishes and linen is adequate. Kitchen appliances were clean and in good condition. The facility food supply had the licensing requirements of nonperishable and perishable. Medication cabinet and first aid kit are stored in kitchen area. Additional facility supplies are stored in locked cabinets in the garage.

The back yard is completely fenced, with one (1) side gate, that was unlocked and easily accessible to open. There are no weapons and bodies of water. There is a covered patio with appropriate seating for residents when sitting outside.

Facility has eight (8) smoke detectors and two (2) carbon monoxide that operate correctly. Fire extinguisher is in the kitchen area with date of purchased 01/20/2023.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASAGAO HOME CARE	FACILITY NUMBER: 197610453
	VISIT DATE: 09/06/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility license and sketch, existing administrator certificate, emergency disaster plan, resident council, and personal rights, complaint procedures were visibly posted. Telephone (661) 522-4275 land line is operable.

Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. Component lll was completed by the applicant representative, Anne Louise Makinose. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted. Copy of this report was provided to Anne Louise Makinose.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2