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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610242
Report Date: 09/14/2022
Date Signed: 09/14/2022 09:47:45 AM

Document Has Been Signed on 09/14/2022 09:47 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, THEFACILITY NUMBER:
197610242
ADMINISTRATOR:DE LIMA, MARY ANN NFACILITY TYPE:
740
ADDRESS:3434 TAMARISK DRIVETELEPHONE:
(661) 266-4835
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 4DATE:
09/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Mary Ann De LimaTIME COMPLETED:
09:45 AM
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LPA Spaeth conducted an unannounced visit and was greeted by two caregivers. LPA observed both caregivers were wearing masks. LPA also observed COVID signs on the front door. LPA's temperature was recorded and LPA answered the COVID questions. LPA stated the purpose of the visit was to do a case management inspection because the facility has residents and has been newly licensed. Caregivers confirmed there are four residents at the facility.

LPA began the tour at 8:50 am and observed the sign in station at the front entrance. The living room contains comfortable furniture. The kitchen has wash your hands sign posted along with hand soap, paper towels and a trash can. The knives were locked in a kitchen drawer, cleaning supplies locked underneath the sink, and resident medications locked in a kitchen cabinet. LPA observed an adequate supply of perishable foods in the refrigerator and frozen meats in the freezer section of the refrigerator. The pantry was well organized and contained seven day supply of various canned goods. LPA observed the backyard contained comfortable seating and the side gate that leads from the back yard to the front yard was not locked. The egress doors were operational and the fire extinguisher was located in the kitchen.

There are four bedrooms in the facility and all four residents were taking a nap after breakfast. The bathrooms contained wash your hands sign, hand soap, paper towels, non skid mats, and trash cans. The door leading to the garage was locked and LPA observed the washer dryer along with the laundry soap was also locked. LPA reviewed resident records and there are no issues to report at this time.

There are no deficiencies to report at this time. Exit interview was conducted, appeal rights and a copy of the signed report was given tot the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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