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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602356
Report Date: 07/14/2021
Date Signed: 07/14/2021 04:31:06 PM

Document Has Been Signed on 07/14/2021 04:31 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:
07/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Ashlee BennettTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA) Melissa Spaeth conducted an unannounced Case- Management - Incident visit. The purpose of this visit is to follow up on a special report submitted to the department on July 13, 2021. LPA met with staff Ashlee Bennett. Administrator Wanda Smith was not at the facility

The licensee reported that on 07/07/2021 two residents were involved in two inappropriate encounters within the facility. The two encounters both occurred on the same day and was reported to Administrator by caregiver. During this visit LPA conducted interviews of the four residents and caregiver regarding the incident. The interviews were conducted from 1:45 pm until 2:25 pm.

LPA toured the facility at 2:30 pm. LPA observed two resident rooms (one female room and one male room) and the staff bedroom located on the west side of the facility along with a bathroom. LPA walked through the kitchen to the east side of the facility passing through a small empty room, the exercise room then to the resident sitting area. There are two resident bedrooms along with resident bathroom and dining area. Caregiver explained one resident room is empty but two female residents share a room. LPA Spaeth observed three residents watching tv.

Record review was conducted by LPA Spaeth from 2:45 pm until 3:26 pm. LPA reviewed two resident files and medication records. Further investigation of the incident is needed at this time. Exit interview conduct, appeal rights discussed. Report will be emailed to Administrator.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2021
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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