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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609667
Report Date: 10/05/2022
Date Signed: 10/05/2022 04:15:16 PM

Document Has Been Signed on 10/05/2022 04:15 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: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: 4DATE:
10/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Alexander ArlosTIME COMPLETED:
03:45 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and observed the COVID signs on the front door. LPA was greeted by two caregivers and LPA stated the purpose of the visit. LPA's temperature was taken and recorded. LPA answered the COVID questions and observed the sign in station at the front door entrance which included thermometer, hand sanitizer and masks. LPA observed caregivers were wearing a mask.

AT 2:35 pm, LPA toured the facility with the caregiver. LPA observed the living room/dining room combination which contained comfortable seating, dining room table, and dining room chairs. The kitchen and family room are combined. LPA observed a two day supply of fresh fruits and vegetables, dairy products and other items in the refrigerator. There is a seven day supply of canned goods within the pantry. LPA observed the cleaning supplies and the knives were locked underneath the kitchen sink. The resident medications were locked in a kitchen cabinet. The sink area contained wash your hands sign, hand soap, paper towels, and a trash can.

The outside area contained a shaded area with lawn chairs and the side gate that leads from the backyard to the front yard was not locked. The resident rooms contained bed, linens, night stand, night lamp and closets. There were fresh linens in the hall closet along with a 90 day supply of PPE items.

There are two bathrooms within the facility which contained wash your hands sign, hand soap, paper towels, and a trash can. However, there were no slip resistant mats within the shower of both bathrooms. Also, a cleaning chemical was located underneath a bathroom sink and the cabinet was not locked. Based upon LPA's observations, the following deficiencies are substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

LPA Spaeth Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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 10/05/2022 04:15 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 10/05/2022 at 03:12 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AAA'S ELDERLY CARE INC
FACILITY NUMBER: 197609667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited

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87303 Maintenance and Operation (3) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
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LPA Spaeth observed there are no non-skid mats located in the two bathrooms, which is an immediate health and safety risk to residents in care.
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Type B
10/05/2022
Section Cited

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87705Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:
(1) Knives...(2) Over-the-counter medication, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
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Based on observation, the licensee failed to ensure cleaning supplies (toxins) were inaccessible to dementia residents which poses an immediate health risk to residents 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:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022


LIC809 (FAS) - (06/04)
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