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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602356
Report Date: 06/18/2021
Date Signed: 06/18/2021 12:34:20 PM

Document Has Been Signed on 06/18/2021 12:34 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:ANA RESIDENTIAL CAREFACILITY NUMBER:
197602356
ADMINISTRATOR:SMITH, WANDAFACILITY TYPE:
740
ADDRESS:1046 EAST LANCASTER BOULVARDTELEPHONE:
(661) 949-0151
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 4DATE:
06/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Wanda SmithTIME COMPLETED:
12:20 PM
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LPA Spaeth conducted an annual inspection/infection control visit with Wanda Smith at 11:00 am. Upon arriving at the facility, LPA Spaeth observed the COVID 19 signs posted on the front door. Administrator greeted LPA at 11:04 am and Administrator took LPA Spaeth's temperature and temperature was recorded at the sign-in station at the front entrance of the facility. LPA Spaeth signed in and was screened by Administrator.

LPA Spaeth began tour by observing the kitchen. LPA observed pantry was well stocked and organized with canned goods, pasta, and other needed food for the facility. LPA Spaeth observed the freezer and the fresh vegetable and fruit sections of the refrigerator were well stocked. LPA observed the locked cabinet containing the knives. Administrator escorted LPA to locked closet in the hallway which contained residents' medications. LPA observed a bathroom which was clean and contained wash your hands sign, hand soap, and paper towels. There were two resident rooms with twin beds in each room which were six feet apart.

LPA Spaeth was escorted to the resident sitting room. LPA Spaeth observed another resident room where a male resident was resting. LPA observed three female residents in a sitting room watching television. LPA observed a second bathroom with wash your hands sign, hand soap, and paper towels. LPA observed the locked garage which contained all cleaning supplies and laundry detergent. LPA Spaeth walked in the backyard and observed the above ground swimming pool had a locked gate but the swimming pool did not have any water. Administrator stated is planning to have the swimming pool removed from the property. LPA Spaeth observed COVID signs throughout the facility. LPA Spaeth concluded at 12:15 pm, report read to the Administrator, report signed. LPA stated will send report by email to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
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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