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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610242
Report Date: 07/19/2024
Date Signed: 07/22/2024 08:27:18 AM

Document Has Been Signed on 07/22/2024 08:27 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PROVIDENCE MANOR, LLC, THEFACILITY NUMBER:
197610242
ADMINISTRATOR/
DIRECTOR:		DE LIMA, MARY ANN NFACILITY TYPE:
740
ADDRESS:3434 TAMARISK DRIVETELEPHONE:
(661) 526-4322
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 5DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Mary Ann De LimaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced required annual visit and was greeted by the Administrator Mary Ann De Lima. LPA Spaeth observed there were two caregivers providing care to the residents. LPA Spaeth confirmed there are five residents. The facility is licensed as an RCFE to serve six residents of which six may be non-ambulatory and two may be bedridden. There is a hospice waiver. LPA confirmed the facility phone number is 661-526-4322.

LPA Spaeth and the Administrator toured the facility at 10:00 am until 10:40 am. LPA Spaeth observed the facility was neat and clean.

Kitchen – LPA observed a seven-day supply of non-perishable food and a two day supply of perishable food items. LPA observed the cleaning supplies were securely locked underneath the kitchen sink and the knives were locked in a kitchen drawer. The medications are locked in a kitchen cabinet and LPA also observed the first aide kit. A fire extinguisher is also located in the kitchen area.

Backyard – LPA Spaeth observed the delayed egress alarm leading out of the sliding glass door to the backyard was properly working. The backyard is a shaded area which contained comfortable seating. The side gate leading from the backyard to the front yard was not locked.

Bedrooms – LPA Spaeth observed there is one resident living in the master bedroom. The delayed egress alarm leading from the bedroom to the backyard was properly working. The room contained bed, linens, night stand, and night lamp. LPA also observed the other three bedrooms also contained the required bed,


Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PROVIDENCE MANOR, LLC, THE
FACILITY NUMBER: 197610242
VISIT DATE: 07/19/2024
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linens, night stand and night lamp. The delayed egress alarm properly worked throughout the facility. LPA Spaeth observed the Administrator added file bins on each resident's door which contained diaper log in reports. LPA Spaeth observed the staff members have recorded when the changes take place.

Bathrooms – At 10:40 am, LPA tested the water temperature in the resident’s bathroom and LPA observed the reading was 111 degrees F. LPA Spaeth observed both bathrooms contained slip resistant mats, hand soap, paper towels, grabe bars, and trash can.

Common Areas – LPA observed comfortable seating in the living room and family room. The dining area contained a dining room table and chairs.

Smoke/Carbon Monoxide Detectors -The smoke detectors were tested at 10:45 am and were operable. The carbon monoxide detector was also operable.

LPA reviewed residents’ files at 10:45 am until 11:30 am. LPA reviewed staff files at 11:30 am until 12:10 pm.

There are no deficiencies to report. Exit interview conducted, and a signed copy of the report was given to the Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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