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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607449
Report Date: 02/01/2022
Date Signed: 02/01/2022 04:35:58 PM

Document Has Been Signed on 02/01/2022 04:35 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:CROMWELL HOMEFACILITY NUMBER:
197607449
ADMINISTRATOR:RENATA GUZAUSKIENEFACILITY TYPE:
740
ADDRESS:29536 CROMWELL AVE.TELEPHONE:
(661) 702-1808
CITY:VAL VERDESTATE: CAZIP CODE:
91384
CAPACITY: 6CENSUS: DATE:
02/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Renata GuzauskieneTIME COMPLETED:
11:32 AM
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Licensing Program Analyst (LPA) Abeye Duguma met with the Renata Guzauskiene for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00am and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a storage room located in a bedroom cabinet. The facility has a total of four (04) bedrooms and two (02) bathrooms of which one is for staff and the other for residents. The facility is fire cleared for six (06) non-ambulatory. The facility is currently occupying six (06) non-ambulatory residents. The facility has outdoor furniture, with a covered shaded area for (umbrella, but put away due to windy/winter season). The facility does not have a swimming pool/body of water. The garage is being used for storage. Laundry detergents, cleaning agents and other toxins are stored in an outdoor storage unit. Food Service/Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

(continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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: CROMWELL HOME
FACILITY NUMBER: 197607449
VISIT DATE: 02/01/2022
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Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living/common and dining room furniture were also checked. The living/common room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Facility has fire sprinkler system. Fire extinguisher is located in the kitchen, observed to be full and last purchased on 08/31/2021. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee and residents' responsible parties. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 110.5°F. Towels and washcloths are not shared. There was enough clean linen available in cabinets located against the kitchen wall. LPA observed medication and first aid kit to be locked and inaccessible to residents, located in the kitchen cabinet.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
LIC809 (FAS) - (06/04)
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