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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607345
Report Date: 12/02/2021
Date Signed: 12/02/2021 11:06:54 AM

Document Has Been Signed on 12/02/2021 11:06 AM - 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:IVAN BANNER BOARDING CAREFACILITY NUMBER:
197607345
ADMINISTRATOR:CYNTHIA TAYLORFACILITY TYPE:
740
ADDRESS:39409 DAYLILY PLACETELEPHONE:
(661) 267-0779
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 6DATE:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Cynthia TaylorTIME COMPLETED:
11:00 AM
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LPA Spaeth conducted an unannounced annual visit and arrived at 9:20 am. LPA observed the COVID signs on the front door and was greeted by the Administrator, Cynthia Taylor. Upon entering the facility, Administrator took LPA's temperature and asked LPA to sign in. LPA answered the Covid questions. Administrator confirmed there are four residents living in the facility, which are ambulatory residents.

LPA observed the living room and dining room which contained comfortable seating. LPA was directed to the family room and kitchen combination. LPA observed comfortable seating in the family room. A kitchen table was also located in the area alongside the kitchen. At 9:45 am, LPA observed the knives were locked in a kitchen cabinet. LPA Spaeth observed the wash your hands sign, hand soap, and paper towels. LPA observed the refrigerator was stocked with fresh fruit, vegetables, and dairy products. All items in the refrigerator were covered and the refrigerator was clean. The freezer contained frozen meats. The pantry was well stocked with cereal and canned vegetables.

LPA was escorted to the locked laundry room and observed the washer and dryer along with laundry detergent. LPA was directed to the backyard and observed comfortable seating in the backyard and the side gate was not locked. LPA Spaeth observed the locked garage which contained PPE supplies which contained N-95 masks and other PPE supplies.

The Administrator then escorted LPA to the second floor and LPA observed a resident room for two residents. The beds were six feet apart and were clean. The residents' room contained lamp, night stand and chest of drawers. LPA observed another resident room and two residents were watching television.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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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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: IVAN BANNER BOARDING CARE
FACILITY NUMBER: 197607345
VISIT DATE: 12/02/2021
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LPA observed the bathroom which contained wash your hands sign, hand soap, paper towels, and a trash can. At 11:00 am, LPA observed the medications were locked in a two-drawer cabinet.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report was provided to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
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