197610167-7-2-2025-31-AS-ERIS-DJ7V4F-20250702160617

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610167
Report Date: 07/02/2025
Date Signed: 07/02/2025 04:06:24 PM

Document Has Been Signed on 07/02/2025 04:06 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	OHANA ELDERLY CARE, INC		FACILITY NUMBER:	197610167
ADMINISTRATOR/ DIRECTOR:	ARAYATA, NATIVIDAD		FACILITY TYPE:	740
ADDRESS:	3052 W MILLING ST		TELEPHONE:	(661) 940-5855
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 4	DATE:	07/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Beatriz Vasquez / Licensee		TIME VISIT/ INSPECTION COMPLETED:	04:16 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/02/25 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by a caregiver. Caregiver contacted the Licensee and informed them LPA was at the facility. Licensee, Beatriz Vasquez met LPA shortly after. LPA Rios explained the purpose of the visit. At 2:00 p.m., LPA Rios conducted a physical plant tour of the facility inside and out. The following was observed: LPA observed appropriate postings by the entry and a visitor sign-in log with a digital thermometer affixed to a wall. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen and medications were observed locked in a kitchen cabinet. Cleaning supplies were observed locked in kitchen cabinet under the sink. Bedrooms: There are five (5) bedrooms designated for residents' use of which one (1) is shared. Resident bedrooms were properly furnished with appropriate bedding, linens, sufficient lighting and required furniture. Hallway cabinets by the bedrooms were observed to store extra linens. The auditory alarms on all exit doors were on and functional at the time of visit. Bathrooms: There are three full (03) bathrooms and one (01) half bathroom. One (1) full bathroom is located in the shared bedroom. Bathrooms were properly supplied with paper towels, hand soap, toilet paper and grab bars. LPA observed the bathroom fixtures to be functional. Hot water temperature was taken from three (03) bathrooms at 3:14 p.m. and read within regulation. (Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OHANA ELDERLY CARE, INC	FACILITY NUMBER: 197610167
	VISIT DATE: 07/02/2025

NARRATIVE

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Common Areas: These included the two (02) living areas and two (02) dining areas. The common areas were clean, clear of clutter and properly furnished. Dining tables sit the capacity of the facility. One of the living areas has a television and fireplace secured with a screen.

Laundry: The laundry room is kept locked and inaccessible to residents in care. Detergents are kept in the laundry room locked.

Garage: The garage is accessible and the facility uses it as a storage room.

The smoke alarms are hard wired and interconnected. Licensee tested the smoke detectors at 3:43 p.m., and they were observed functional. The facility also has fire doors that automatically closed when the smoke detector were tested. LPA observed a carbon monoxide detector by the kitchen. LPA tested carbon monoxide detector and it was observed functional. The fire extinguisher is located in the kitchen and was observed fully charged with purchased date 06/09/2025.

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards and fenced in. No bodies of water were observed.

Resident Files/ Staff Files / Facility Files: At 2:16 p.m., LPA conducted a file review of four (04) out of four (04) resident records. At 2:53 p.m. LPA also conducted a file review of staff records and facility records to insure forms and training are up to date and compliance with licensing forms. LPA reviewed facility's Emergency Disaster Plan (LIC610E) and Certificate of Liability Insurance.

Medications: At 3:11 p.m. Medication and Medication Records were reviewed for proper documentation.

No deficiencies observed during today's visit. Exit Interview conducted. A copy of the report provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

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