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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609667
Report Date: 09/03/2021
Date Signed: 09/03/2021 11:55:08 AM

Document Has Been Signed on 09/03/2021 11:55 AM - 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:AAA'S ELDERLY CARE INCFACILITY NUMBER:
197609667
ADMINISTRATOR:REYES, MARICELFACILITY TYPE:
740
ADDRESS:3960 WOBURN CTTELEPHONE:
(661) 350-2232
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 6DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Alexander ArlosTIME COMPLETED:
11:30 AM
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LPA Spaeth conducted an unannounced annual visit and arrived at approximately 9:45 am. LPA Spaeth approached the front door and observed the required COVID signs. LPA was greeted by caregiver, Alexander Arlos who was wearing a mask. LPA Spaeth stated the purpose of the visit was to conduct an annual inspection. LPA confirmed there are six residents in the facility. LPA's temperature was recorded, LPA signed in and answered all the necessary COVID questions. LPA observed the sign in station which contained the sign in sheet, PPE supplies (masks, gloves,etc), hand sanitizer, wipes, and thermometer.

LPA Spaeth confirmed there are five resident rooms and one live-in staff room. LPA began the tour and observed the living room/dining room combination. LPA Spaeth was greeted by caregiver Analyn Charley who was wearing a mask. LPA observed the kitchen was neat and clean. LPA observed the knives and cleaning supplies were locked under the kitchen sink. LPA observed wash your hands sign, hand soap, and a trash can. Caregiver Arlos unlocked the kitchen cabinet which contained all the residents' medications. LPA observed sirloin steaks were being prepared for the noon meal. The refrigerator contained the required supply of perishable fruits and vegetables and an ample supply of frozen meats and vegetables. The pantry was well stocked with canned goods, pasta and other non perishable items.

LPA observed the three bathrooms all contained wash your hands signs, hand soap, paper towels, and trash cans. LPA observed two resident rooms and observed the rooms were neat and clean. The rooms contained all the required furniture (night stand, lamp, closet) and linens for the comfort of the residents. LPA observed an adequate supply of hygiene items available for residents and a 90-day supply of PPE.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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 2
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: AAA'S ELDERLY CARE INC
FACILITY NUMBER: 197609667
VISIT DATE: 09/03/2021
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LPA was escorted to the laundry room which lead to the garage. Caregiver Alexander Arlos unlocked a cabinet which contained the laundry soap. LPA observed a second refrigerator in the garage which contained additional frozen meats and vegetables. LPA then walked out to the backyard and observed a shaded area with comfortable chairs available for the residents. LPA observed the gate that leads from the backyard to the front yard was unlocked. LPA Spaeth concluded the tour at approximately 9:22 am.

At approximately 10:45 am, LPA confirmed both caregivers, Analyn Charley and Alexander Arlos both cleared the required fingerprint clearance. The phone number for 661-494-8059.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and LPA Spaeth confirmed a copy of the signed report will be emailed to Administrator mreyes355@yahoo.com.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC809 (FAS) - (06/04)
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