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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602356
Report Date: 07/21/2021
Date Signed: 07/21/2021 01:06:28 PM

Document Has Been Signed on 07/21/2021 01:06 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: 5DATE:
07/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ashlee BennettTIME COMPLETED:
12:15 PM
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LPA Spaeth arrived at the facility at 10:30 am. LPA was greeted by caregiver, Ashlee Bennett. Upon entering the living room, LPA observed a female watching television. Caregiver stated new resident had moved into the facility.

LPA was escorted to the resident sitting area. LPA observed two females and one male watching television. Caregiver stated residents are getting showers today and had been assisting residents. Administrator arrived at the facility at 10:45 am and LPA was greeted by Administrator. LPA Spaeth explained the purpose of the visit was to conduct a records review.

LPA Spaeth began record review at 10:50 am. LPA Spaeth reviewed resident records and staff records. LPA completed record review at 12:00 pm.

Further investigation is needed at this time. Exit interview conducted, appeal rights discussed. LPA confirmed with Administrator that a copy of the report will be emailed to Administrator via email.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
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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