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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602356
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:50:15 PM

Document Has Been Signed on 06/21/2022 02:50 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:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Wanda Smith, LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Shira Stamps arrived at the facility for an unannounced one (1) year Required visit. LPA arrived at 1:40 pm, and was greeted by Licensee Wanda Smith, LPA informed the Licensee of the purpose of the visit. All clients were at their day programs.

A tour of the physical plant was conducted with the Licensee at 1:45 pm. The facility has five (5) bedrooms and three (3) bathrooms currently occupying four (4) clients. One (1) bedroom and one (1) bathroom is designated for staff use only. One (1) bedroom is designated for the gym. The facility is Fire Cleared for two (2) non-ambulatory and a hospice wavier for four. The facility currently has three (3) ambulatory and one (1) non- ambulatory clients.

Infection control: LPA reviewed the mitigation plan approved on 3/30/21. The facility is following current infection control recommendations. Upon arrival LPA was screened by the Licensee and asked all infection control questions. LPA was asked to sign-in and sanitize hands.

Living and dining
At 1:45 pm, LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 82°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 2:01 pm. At 1:55pm, LPA observed the second living, dining room, and kitchen to be neat and clean.

Food Inspection
LPA conducted a tour of the kitchen around 1:48 pm and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to clients in care. CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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: ANA RESIDENTIAL CARE
FACILITY NUMBER: 197602356
VISIT DATE: 06/21/2022
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Laundry
The Laundry room is located near the garage. No chemicals/hazardous items were found. There is one (1) fire extinguisher located in the laundry room. The Fire extinguisher was observed to be full and last serviced 9/12/21.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client. The medication cabinet was observed to be locked in the hallway.

Bathrooms
LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 1:54 pm and measured within regulation at 112.8 degrees F.

Physical environment
LPA toured the outside area of the facility at 1:57 pm. LPA observed a covered shaded area for clients. The above ground pool was taken down, and there are now no bodies of water on the premises. LPA observed a shed used for emergency supplies and storage.

Garage
At 2:00 pm, LPA observed the locked garage to be attached to the facility and is currently being used for storage, an extra refrigerator, PPE supplies, and chemicals/hazardous items.

Administrative: Annual fee is current.

An exit interview was conducted, and a copy of this report was given to the Licensee.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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