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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609325
Report Date: 05/26/2021
Date Signed: 05/26/2021 03:14:46 PM

Document Has Been Signed on 05/26/2021 03:14 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:INDEPENDENT ENTERPRISE HEALTH CARE INCFACILITY NUMBER:
197609325
ADMINISTRATOR:RFACILITY TYPE:
740
ADDRESS:36722 ROSE STTELEPHONE:
(661) 917-4380
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 4DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:TIME COMPLETED:
12:00 PM
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LPA Spaeth conducted an infection control visit at the facility. Upon arrival to the facility, LPA observed the COVID signs posted on the door. At 10:45 am, LPA was greeted by caregiver, Gabriel Bogle who was wearing a mask. Caregiver took LPA’s temperature, and LPA signed in at the front door. LPA observed the sign-in area which contained hand sanitizer, log book, and masks. Caregiver confirmed there are four ambulatory residents. LPA observed the living room where resident was sitting in a chair and LPA noted the living room was neat and clean. LPA was escorted to the dining room table. Administrator was called by phone and LPA spoke to Administrator, James Durando. Administrator stated driving resident to the dentist but stated caregiver, Gabriel Bogle, would escort LPA throughout the facility.

LPA Spaeth began the tour in the kitchen and saw hand soap, wash your hands sign, paper towels, and trash can. The refrigerator contained fresh vegetables, fruit, eggs, bread and the freezer contained frozen meats. The pantry was stocked with canned goods. Caregiver unlocked a cabinet above the refrigerator which contained the knives. Within the dining room, caregiver unlocked a two drawer cabinet and LPA observed the residents’ medications. LPA observed the kitchen soap, paper towels, and trash can in the kitchen. However, the kitchen did not contain a “wash your hands” sign.

LPA Spaeth observed each resident had own bedroom which was properly furnished with lamp stand, lamp, and chair. All rooms were neat and clean. LPA Spaeth was greeted by two residents during the tour and LPA introduced self to residents. Both stated had breakfast that morning along with coffee. The two bathrooms were clean and contained wash your hands sign, hand soap, paper towels and a trash can. The master bedroom is a vacant room but the room was neat and clean. Caregiver showed LPA the resident temperatures and symptoms are recorded on a paper that is attached to a clipboard on the

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2021
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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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: INDEPENDENT ENTERPRISE HEALTH CARE INC
FACILITY NUMBER: 197609325
VISIT DATE: 05/26/2021
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door so that caregivers do not forget to take daily temperatures. Caregiver stated temperatures are recorded every morning at 7:00 am.

Within the hallway, caregiver unlocked a door and LPA observed the laundry room area which contained washer and dryer, laundry detergent, and cleaning supplies. LPA Spaeth also observed a 30-day supply of all PPE which included N-95 masks, gowns, gloves, and hand sanitizer. LPA Spaeth also observed the linen closet which was stocked with clean linens and towels. Caregiver stated staff are required to sanitize all frequently touched items (doorknobs, kitchen table, etc) every hour and stated the facility is cleaned several times a day. LPA Spaeth observed the backyard which was furnished with seating for the residents.

LPA concluded the tour. Exit interview was conducted and Appeal Rights were discussed. LPA informed Administrator a copy of the report will be sent to Administrator for signature. LPA instructed Administrator to sign and send report to LPA via email.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC809 (FAS) - (06/04)
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