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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608302
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:32:31 PM

Document Has Been Signed on 12/05/2024 02:32 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LANCASTER HAVEN RCFEFACILITY NUMBER:
197608302
ADMINISTRATOR/
DIRECTOR:		MARIA MAXIMA BASCOS, RNFACILITY TYPE:
740
ADDRESS:1755 WEST LANCASTER BLVD.TELEPHONE:
(661) 212-7939
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 5DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Mildred Tripp-Co administratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 12/05/2024 at approximately 09:50 am, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by Co-Administrator Mildred Tripp and disclosed the reason for today’s visit. Manager,Teodoro Tripp, arrived shortly after where he assisted with today’s visit.
LPA asked for census, staff, and resident files. LPA conducted a physical plant tour at approximately 11:00 am and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with four (4) bedrooms and three (3) bathrooms currently occupying five (5) residents. One (1) bedroom is designated for staff use and additional room is being used as an office/staff room. The facility is fire cleared for six (6) non-ambulatory residents. Hospice waiver recently approved from two (2) to six (6) residents.

Required postings such as Personal Rights, Facility Sketch, and Emergency/Disaster Plan were located at the main entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

Both living and dining rooms are neat, clean, and organized. Both rooms are properly furnished and in good repair. Fireplace observed to be properly covered and inaccessible to residents. The facility maintains a comfortable temperature at 64°F. Fire extinguisher located in hallway and last inspected on 06/03/24. Additional required postings were observed aside the kitchen such as: Yes poster and Ombudsman.

The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Knives and sharps observed to be locked in a kitchen drawer near the stove and inaccessible to residents. Cleaning solutions are kept locked in a cabinet under the sink. Stove observed to be working and in proper condition. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 5
Document Has Been Signed on 01/22/2025 11:51 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/22/2025 10:35 AM


Created By: Angelica Segovia On 12/05/2024 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LANCASTER HAVEN RCFE
FACILITY NUMBER: 197608302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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4
This deficiency was amended. Please see 809-D created 01/22/2025.
POC Due Date:
Plan of Correction
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4
Section Cited
Deficient Practice Statement
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2
3
4
This deficiency was amended. Please see 809-D created 01/22/2025.
POC Due Date:
Plan of Correction
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3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Angelica Segovia
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/22/2025 11:52 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/22/2025 10:40 AM


Created By: Angelica Segovia On 12/05/2024 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LANCASTER HAVEN RCFE
FACILITY NUMBER: 197608302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
This deficiency was amended. Please see 809-D created 01/22/2025.
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Angelica Segovia
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/22/2025 11:54 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/22/2025 10:44 AM


Created By: Angelica Segovia On 12/05/2024 at 01:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LANCASTER HAVEN RCFE
FACILITY NUMBER: 197608302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
This deficiency was amended. Please see 809-D created 01/22/2025.
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Angelica Segovia
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LANCASTER HAVEN RCFE
FACILITY NUMBER: 197608302
VISIT DATE: 12/05/2024
NARRATIVE
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The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. There is a shed at the backyard being used as storage and observed to be locked during visit.

Smoke detectors and carbon monoxide observed to be working properly and were tested.

The Garage can be accessed from the inside of the facility. The garage is attached to the home and is being used as storage. The garage is observed to be locked and inaccessible to residents. Laundry room is located adjacent to the kitchen. Laundry detergents, cleaning solutions and other chemicals and toxins are locked and secured in the laundry room.

The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. LPA observed three (3) out of five (5) residents were bedridden without proper fire clearance approval. Residents have sufficient personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilets and showers. The hot water temperature was measured at 115.3°F. Towels and washcloths are not shared. Sufficient availability of clean lien stored in hallway cabinet.

Medications: LPA observed medication in the medication cart to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the living room.

Resident records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated.

An exit interview was conducted, one (01) citation was issued, appeals rights and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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