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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602316
Report Date: 02/01/2022
Date Signed: 02/01/2022 04:37:58 PM

Document Has Been Signed on 02/01/2022 04:37 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SANTA CLARITA HOME FOR THE ELDERLY #3FACILITY NUMBER:
197602316
ADMINISTRATOR:FRASER, NENITAFACILITY TYPE:
740
ADDRESS:28000 TOTHILL DRIVETELEPHONE:
(661) 296-7674
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY: 6CENSUS: DATE:
02/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Shirley Rivera, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with the Shirley Rivera, Administrator, for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 12:05pm and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in front of the building. The facility has sufficient stock of PPE in a storage room located in the garage. The facility has a total of four (04) bedrooms, of which one (01) is for staff and two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory residents and a hospice waiver for three (03). The facility is currently occupying three (03) non-ambulatory residents. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. The garage is being used for storage. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. Food Service/Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

(continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SANTA CLARITA HOME FOR THE ELDERLY #3
FACILITY NUMBER: 197602316
VISIT DATE: 02/01/2022
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Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living and dining room furniture were also checked. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the dining, observed to be full and last inspected on 09/27/2021. Staff room is located near the front entrance. No medications are observed in the staff room. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 118.9°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinet and some in the residents’ rooms. LPA observed medication and first aid kit to be locked and inaccessible to residents, located in a locked coat closet near the front entrance.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
LIC809 (FAS) - (06/04)
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