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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608302
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:02:09 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/22/2025 12:02 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: 3DATE:
01/22/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Teodoro Tripp- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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This report was created to amend the LIC809-C and LIC809-D pages found on the One Year Required Annual report issued 12/05/2024. The pages were amended to correct the number of citations from four (04) to one (01).

On 01/22/2025 at approximately 10:00 AM, Licensing Program Analysts (LPAs), Angelica Segovia and Abeye Duguma conducted an unannounced continuation annual visit. Upon arrival LPAs were 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.

Based on LPA's observations, interview and record review, the licensee did not comply with Title 22, Division 6, Chapter 8, Article 11, Health-Related Services and Conditions 87606 Care of Bedridden Residents. Records revealed that 3 out of 5 persons are bedridden which poses an immediate health, safety or personal rights risk to persons in care. The facility also did not notify the fire authority having jurisdiction within 48 hours of accepting or retaining persons who are bedridden, as specified in Health and Safety Code section 1569.72.

No other immediate health and safety issues observed. Appeal Rights given. Exist interview conducted 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
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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Document Has Been Signed on 01/22/2025 12:02 PM - It Cannot Be Edited


Created By: Angelica Segovia On 01/22/2025 at 11:00 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LANCASTER HAVEN RCFE
FACILITY NUMBER: 197608302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
Section Cited
CCR
87606(a)(b)

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87606 Care of Bedridden Residents(a)..The licensee shall be permitted to accept and retain residents who are or shall become bedridden, if all the following conditions are met.. (b)A licensee shall notify the fire authority... within 48 hours of accepting or retaining any person who is bedridden
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The Administrator/licensee will send LPA documentation showing approval of fire clearance for bedridden residents.
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as specified in Health and Safety Code section 1569.72. This requirement is not met as evidenced by; Based on record review, interview and observations, 3 out of 5 persons are bedridden which poses an immediate health, safety or personal rights risk to persons in care.
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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)
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