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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609016
Report Date: 06/24/2021
Date Signed: 06/29/2021 04:37:11 PM

Document Has Been Signed on 06/29/2021 04:37 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:ARK CARE HOME LLCFACILITY NUMBER:
197609016
ADMINISTRATOR:MANDAC, ADELAIDA QFACILITY TYPE:
740
ADDRESS:37616 RIBBON LANETELEPHONE:
(661) 526-4066
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 3DATE:
06/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Adelaida Mandac, Richard MandacTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required annual visit. LPA met with administrator Adelaida and Richard. They were informed regarding the visit and mitigation plan was reviewed.

Upon entry LPA observed visitation signs posted. The front table had thermometer, log in sheet, and signs atT
the entry way regarding Covid signs and symptoms. The administrator took LPA temperature and listed temp A tour of the facility was conducted and each room was observed. The smoke detector was checked for operation.

The mitigation plan was checked with the administrator's and an updated one shall be submitted to LPA. LIability insurance is on file and a copy will be sent to LPA when mitigation plan is submitted.

At the current time there are no deficiencies observed. The report has been signed and will be emailed to administrators.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Angelica Arambulo
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2021
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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