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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610683
Report Date: 12/24/2024
Date Signed: 12/24/2024 12:17:11 PM

Document Has Been Signed on 12/24/2024 12:17 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ADULT CARE INSTITUTEFACILITY NUMBER:
197610683
ADMINISTRATOR/
DIRECTOR:		LEE, TRACIIFACILITY TYPE:
735
ADDRESS:6917 TULETTE LANETELEPHONE:
(661) 526-5973
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 0DATE:
12/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jacquline Page- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 12/24/24, at approximately 10:00 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an announced Pre-licensing visit. LPA met with the applicant representative Joseph Lee.

An application was submitted to Community Care Licensing Division-CCLD on 07/14/2024, Initial license for a Adult Residential Facility (ARF), 18 to 59 years old. The requested capacity is for four (4) ambulatory clients and fire clearance was approved on 10/11/2024.

Structure: The facility is a two-story building with five (5) bedrooms and three (3) bathrooms and with a swimming pool on the premises. One room is designated for staff room only with its own bathroom.

Entrance: There is only one (1) entrance being utilized. Required postings such as: Facility sketch, Personal Rights of Individuals with Developmental Disabilities, and See Something Say Something posted along hallway leading to bedrooms.

Toxins, cleaning solutions, and laundry detergents are kept locked under the sink in the kitchen inaccessible to clients.

Living/Dining area: The living room is neat, clean, and organized with sufficient seating for both clients and staff. The dining area is also neat, clean, and organized. Both rooms are properly furnished and in good repair. The facility maintains a comfortable temperature of seventy (70) degrees. No firearms observed or will be maintained on the premises. Fireplace is covered and inaccessible to clients.

Client/staff files: Client and staff files will be kept locked in filing cabinet in office located alongside the living room.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/24/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ADULT CARE INSTITUTE
FACILITY NUMBER: 197610683
VISIT DATE: 12/24/2024
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Kitchen: Sufficient supplies of dishes, cups, and silverware located within the kitchen cabinets and drawers. Sharps are stored in kitchen pantry locked inaccessible to clients. Sufficient supply of food such as: canned goods, bottles of water, cereal were observed in the garage. Kitchen appliances are working and are in good repair. First-aid kit observed as well. There is a working telephone on the premises.

Emergency: Fire extinguisher located in the kitchen. Fire extinguisher is not dated or without purchase receipt.

Medications: Medication will be stored in locked filing cabinet next to client/ staff files. Monthly medication will be stored in filing cabinet within the office. Medication storage is equipped with a lock to ensure medications will not be accessible to clients. First aid with Manuel, scissors, tweezers, band aids, and digital thermometer located with medication storage.

Bedrooms: The bedrooms are missing night stands with proper lighting. LPA observed proper bed and seating. Window coverings are in good repair, not broken or damaged.

Bathroom: The bathrooms are in proper condition and will be equipped with sufficient personal hygiene for each client. Towels and washcloths will not be shared. Bathtub was not working and will be fixed prior to licensing approval.

Hallways: Hallway are properly lighted. Extra linens/covers observed in storage cabinet within the passageway.

Staff room: staff room locked inaccessible to clients.

Water Temperature: The water temperature was measured in the bathrooms at 105.4 Fahrenheit and is within regulations.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ADULT CARE INSTITUTE
FACILITY NUMBER: 197610683
VISIT DATE: 12/24/2024
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Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested at 11:00 am.

Garage: The garage can be accessed from inside the facility. The garage will be used for storage. The garage is equipped with two working refrigerators that will be utilized for storage and emergency food. The garage is locked inaccessible to clients.

Laundry: Laundry Room is located on the first floor. Dryer and washer observed to be in good repair. Laundry room is locked inaccessible to clients.

Outside: The outside is clean, free of hazards, and is properly furnished with sufficient seating. A shaded area for clients was observed as well. Storage unit observed to be locked and inaccessible to clients.



Pool: The swimming pool is appropriately fenced and inaccessible to clients.

Administration: The facility had submitted an Emergency and Disaster Plan for Adult Community Care Facilities and Infection plan.

The Component III Orientation ARF was shown/reviewed with the facility representatives.

Facility is not yet in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) once LPA receives photos of corrections. You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report issued to the facility representative Joseph Lee.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC809 (FAS) - (06/04)
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