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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608302
Report Date: 01/21/2022
Date Signed: 01/21/2022 03:22:00 PM

Document Has Been Signed on 01/21/2022 03:22 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:LANCASTER HAVEN RCFEFACILITY NUMBER:
197608302
ADMINISTRATOR:MARIA MAXIMA BASCOS, RNFACILITY TYPE:
740
ADDRESS:1755 WEST LANCASTER BLVD.TELEPHONE:
(661) 212-7939
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Mildred TrippTIME COMPLETED:
03:15 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit to the facility and was greeted by the Administrator, Mildred Tripp. Upon approaching the front door, LPA observed the required COVID signs on the door. Administrator was wearing a mask. The Administrator asked the COVID questions and took LPA's temperature. LPA observed the sign in station which contained the sign in sheet, thermometer, hand sanitizer, and masks at the front entrance.

LPA was escorted to the dining room and LPA observed a dining room table and chairs. The Administrator confirmed there are three residents in the facility and stated the residents are staying in his/her room during this time to stay safe. Administrator is delivering meals to the resident's rooms. LPA observed the living room contained comfortable seating for the residents.

LPA was then escorted to the kitchen and observed a five-day supply of fresh fruits and vegetables in the refrigerator, frozen meats in the freezer, and a seven-day supply of canned goods in the pantry. LPA observed wash your hands sign, hand soap, paper towels, and a trash can with a lid in the kitchen. The knives were locked in a cabinet, the cleaning supplies were locked underneath the sink, and medications were also locked in the kitchen.

LPA observed the bathroom contained wash your hands sign, hand soap, paper towels, and a covered trash can. The outside area contained comfortable seating for residents and the gate surrounding the property was not locked. LPA observed the entire facility was neat and clean.

All residents were resting in their rooms during LPA's visit. LPA also observed fresh linens in a hallway closet.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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