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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607020
Report Date: 07/01/2021
Date Signed: 07/01/2021 04:04:57 PM

Document Has Been Signed on 07/01/2021 04:04 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:JOE-SEPHINE RESIDENTIAL CARE FAC. FOR THE ELDERLYFACILITY NUMBER:
197607020
ADMINISTRATOR:JOSEPHINE C. SANOYFACILITY TYPE:
740
ADDRESS:615 CURVE CIRCLETELEPHONE:
(661) 942-4307
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
07/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Josephine SanoyTIME COMPLETED:
03:30 PM
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LPA Spaeth conducted an annual/infection visit and arrived at 2:35 pm. Upon walking to the front door, LPA observed the COVID 19 signs. Administrator Josephine Sanoy greeted LPA and Administrator was wearing a mask. LPA observed the sign in station at the front door and Administrator took LPA's temperature. The sign in station contained sign in sheet, thermometer, hand sanitizer. LPA confirmed there are three residents living in the facility.

Upon entering the facility, LPA observed resident sitting comfortably watching television. LPA Spaeth walked into the dining room and observed a resident sitting at the kitchen table. LPA viewed the kitchen and observed wash your hands sign, hand soap, paper towels, and a covered trash can. LPA Spaeth observed the knives and medications were locked in a cabinet. LPA observed an adequate supply of fresh fruits and vegetables in the refrigerator along with frozen meats in the freezer section. LPA also observed an ample supply of canned goods in the pantry.

LPA Spaeth viewed two resident rooms and observed the rooms were clean. Administrator explained one resident was napping in room. LPA observed the two bathrooms and saw wash your hands sign, hand soap, paper towels, and trash cans in the bathrooms. LPA Spaeth observed an ample supply of PPE, and hygiene items available for use. LPA Spaeth observed lawn chairs available for seating in the backyard. LPA Spaeth observed the laundry area was located in the garage and the garage was locked.

There are no deficiencies are to report. Exit interview was conducted, appeal rights discussed, and LPA stated will send report to Administrator via email.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2021
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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