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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610621
Report Date: 10/29/2024
Date Signed: 10/29/2024 10:57:46 AM

Document Has Been Signed on 10/29/2024 10:57 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HARCELLE RESIDENTIAL HOME CARE, INC. - 2FACILITY NUMBER:
197610621
ADMINISTRATOR/
DIRECTOR:		ROYO, MARIA CECILIAFACILITY TYPE:
735
ADDRESS:43732 SECURE PL.TELEPHONE:
(661) 418-6017
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 0DATE:
10/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Maria RoyoTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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 Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection at this facility and met with the applicant representative Maria Royo. The applicant Licensee is "HARCELLE RESIDENTIAL HOME CARE, INC. - 2". A fire clearance was approved on 05/30/2024 for two (2) non ambulatory clients and two (2) ambulatory clients for a total capacity of four (4) clients.

The facility is a single story house with a total of five (5) bedrooms and two (2) bathrooms. A tour of the physical plant was initiated at approximately 9:11 a.m. and the following was observed:
LPA observed required postings through out the facility.

BEDROOMS: There are five (5) bedrooms, of which four (4) are designated for clients' use, one (1) of the four (4) client bedrooms is shared. Clients' bedrooms were furnished with beds, night stand, chairs, dressers, bedding and linens. The bedrooms have sufficient lighting and storage.

BATHROOMS: The facility has two (2) shared bathrooms for clients' use. One bathroom is located in the shared bedroom. The bathrooms were observed to have the proper fixtures, and supplies. Under bathroom sink cabinets were observe locked and stored cleaning products. The hot water temperature measured at 114°F, within regulation.

LAUNDRY ROOM: The laundry room is accessible to clients. Laundry detergents and other cleaning agents were locked in the laundry room. The attached garage is through the laundry room. The garage is used to store extra facility supplies.



Smoke detectors were tested and observed to be operable, they are hardwired and interconnected. A carbon monoxide detector was observed operable. Two (2) Fire extinguishers were observed fully charged with service date 04/29/2024. (Continued on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HARCELLE RESIDENTIAL HOME CARE, INC. - 2
FACILITY NUMBER: 197610621
VISIT DATE: 10/29/2024
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(continued from LIC809)
COMMON AREAS: These included the living room and the dining area. Living room was furnished with couches that sit the capacity of the facility. The dining table sits the capacity of the facility. There were no visible immediate hazards. Extra linens, towels, and toiletries were observed in various linen closets through out the facility.

KITCHEN: The kitchen is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of emergency and 7-day non perishable supply of food. Knives were observed locked in a kitchen drawer. Cleaning supplies are stored in a locked cabinet under the sink. There is a working telephone line accessible to clients.

STAFF/CLIENT/MEDICATIONS: The medication cabinet is located by the kitchen observed locked. A complete first aid kit is located in the medication closet. Staff and client records will be kept in locked cabinet by medication.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a covered patio and backyard furniture to accommodate the clients.

Component III was conducted with the Licensee representatives.

Pre-Licensing is complete and this facility has no deficiencies. This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
Exit interview conducted. Copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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