361800233-5-19-2021-18-AS-JGEE-C36QUQ-20210519122906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800233
Report Date: 05/19/2021
Date Signed: 05/19/2021 12:29:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CARMEL CARE HOME		FACILITY NUMBER:	361800233
ADMINISTRATOR:	DENSEN, ROMMEL		FACILITY TYPE:	740
ADDRESS:	11971 4TH AVE		TELEPHONE:	(760) 488-1828
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	6	CENSUS: 4	DATE:	05/19/2021
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Licensee's/Administrator's Rommel and Caroline Densen		TIME COMPLETED:	12:40 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	On 5/19/21 Licensing Program Analyst (LPA) Javina George conducted an announced visit for the purpose of an Increase of Capacity. Upon arrival LPA met with Licensee's/Administrator's Rommel and Caroline Densen whom assisted with the inspection. The facility is a single story house with (7) resident bedrooms, and 3 bathrooms 1 of which is private. A living room, office, family room, kitchen with dining area, laundry room, covered patio, garden area, garage and a backyard with 1 shed located on the premises, which is being used for storage. On 04/21/2021, the City of Hesperia Fire Protection Bureau approved the facility for 10 non-ambulatory residents, which 2 may be bedridden. The 2 bedridden residents will reside in a shared room, (bedroom #7). The Administrator's also submitted a request for an increase of hospice residents. The facility has an approved hospice waiver for 10. During today's inspection, LPA toured the interior and exterior of the facility. The medications will be centrally stored and locked in a file cabinet, located inside of the living room/dining area. The smoke and carbon monoxide detectors are operable. There is 1 fire extinguisher, hung on the outside wall of the kitchen. All cleaning supplies are locked underneath the kitchen sink and a cabinet located inside of the laundry room. The sharp objects are locked in the kitchen in a drawer next to the pantry. All doors, and passageways are clear from obstruction. There were no pools or bodies of water on the premises. There is an fire place located in the living room but is not used and is properly screened. All beds have the required linen and supplies. There was a sufficient amount of clean linen and hygiene items. There was appropriate lighting in each room.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CARMEL CARE HOME	FACILITY NUMBER: 361800233
	VISIT DATE: 05/19/2021

NARRATIVE

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The hot water tested and ranged from 105.1-109.5 degrees F. All kitchen appliances are operable. The bathrooms are equipped with grab bars and non-skid floor mats and/or surfaces. The facility is equipped with emergency flashlights that is assessable to all .

All garbage cans have tight fitting lids. The facility is stocked with a 2 day supply of perishables and a 7 day supply of non-perishable food items. The facility was stocked with dishes, tableware, and utensils in good repair and enough for the capacity. The resident and staff files will be locked in a cabinet in the office. LPA observed the emergency disaster plan, facility sketch, personal rights, Covid postings and complaint procedures that are hung on a cork board throughout the hallway

There is adequate seating in the common areas. There is 1 stocked first aid kit with 2 manuals. The facility is stocked with activities such as board games and puzzles, which provide entertainment and encourage socialization for the residents. The activities are located outside in a cabinet on the patio. The resident's also have access to a garden located in the backyard.

A copy of this report was provided and discussed with Licensee's/Administrator's Rommel and Caroline Densen.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC809 (FAS) - (06/04)

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