197610242-6-10-2022-31-AS-MSPH-CF9PJB-20220610112117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610242
Report Date: 06/10/2022
Date Signed: 06/10/2022 11:21:42 AM

Document Has Been Signed on 06/10/2022 11:21 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:	PROVIDENCE MANOR, LLC, THE		FACILITY NUMBER:	197610242
ADMINISTRATOR:	DE LIMA, MARY ANN N		FACILITY TYPE:	740
ADDRESS:	3434 TAMARISK DRIVE		TELEPHONE:	(661) 266-4835
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 6		CENSUS: 4	DATE:	06/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mary Ann De Lima		TIME COMPLETED:	11:30 AM

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	LPA Spaeth arrived at the facility at 9:00 am and was greeted by the Administrator. LPA's temperature was recorded and LPA answered the COVID screening questions and signed in at the front entrance. The administrator confirmed there are four residents in the facility. LPA conducted the Comp III presentation with the Administrator from 9:05 am until 9:50 am.. LPA and the Administrator began the tour at 9:50 am. Upon entering the facility, LPA observed the living room/dining room combination. The living room contained comfortable seating and the dining room contained a dining room table with chairs. The room was spacious and clean. LPA entered the kitchen/family room combination and observed a five-day supply of fresh fruits and vegetables in the refrigerator. The freezer section contained frozen meats. LPA observed a seven-day supply of canned goods, pasta, and rice within the pantry. The cleaning supplies were locked underneath the sink and the knives are safely locked in a kitchen cabinet. LPA also observed the locked cabinet which contains the residents’ medications and the first aid kit. The family room contains comfortable seating and a television. A resident was enjoying an activity with a caregiver and another resident was sitting on the couch reading a magazine. LPA was then escorted outside and observed a covered patio with comfortable patio furniture. The side gate was unlocked that leads from the backyard to the front yard. LPA observed four resident rooms which all contained a bed, linens, chair, night stand, lamp, chest of drawers, and a closet. LPA observed the resident rooms each contained a doors which lead to the outside of the facility. The egress alarms were properly working throughout the facility.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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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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: PROVIDENCE MANOR, LLC, THE	FACILITY NUMBER: 197610242
	VISIT DATE: 06/10/2022

NARRATIVE

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The staff room was locked. The hallway cabinets contained an adequate supply of linens, towels, and PPE supplies. LPA was escorted to the locked garage which contained the washer and dryer along with a locked cabinet where the laundry supplies are kept.

LPA observed the two bathrooms which contained soap, paper towels, trash can, grab bars and slip resistant mats in the walk-in showers. The bathrooms were neat and clean.

The water temperature was checked at 11:43 am and was 112.0 degrees F. At 11:45 am, the smoke and carbon monoxide detectors were checked and are working properly. LPA observed three fire extinguisher. There is a fire extinguisher in the kitchen, hallway, and garage. The Let Us Know signs as also posted within the facility.

Upon LPA's conclusion of the tour, LPA did not observe any issues at this time. Exit interview was conducted, appeal rights discussed, and a copy of the report was given to the Executive Director.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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