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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610333
Report Date: 10/19/2022
Date Signed: 10/19/2022 11:16:31 AM

Document Has Been Signed on 10/19/2022 11:16 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:HUMBLE HAVEN RCFE IVFACILITY NUMBER:
197610333
ADMINISTRATOR:DE LAS ALAS, NICOLEFACILITY TYPE:
740
ADDRESS:4036 TOURNAMENT DRIVETELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 0DATE:
10/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nicole De Las AlasTIME COMPLETED:
11:15 AM
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LPA Spaeth conducted a pre-licensing visit and was greeted by the Administrator. Upon arrival LPA observed the sign in station which contained a thermometer, sign in sheet, and hand sanitizer. LPA's temperature was recorded by Administrator.

LPA conduced the Comp III session at 9:10 am until 10:00 am. LPA was escorted throughout the facility by Administrator at 10:05 am. The water temperature was tested at 10:10 am and LPA recorded the temperature at 116.6 F. LPA observed the facility contains an activity room where games and work out equipment were available. The kitchen, dining room, and family room are combined. LPA observed a two-day supply of fresh fruits and vegetables in the refrigerator and a seven-day supply of non-perishable food was stored in the pantry. The knives, first aid kit, and medications are locked in a kitchen cabinet. The cleaning supplies were locked underneath the kitchen sink. LPA observed paper towels, hand soap, and trash can were located near the kitchen sink. The fire extinguisher was located near the kitchen area.

LPA exited the patio door and observed the alarm alert signal was properly working when exited to the backyard. LPA observed comfortable seating and the side gate leading to the front yard was not locked. There are five bedrooms which all contained bed, linens, lamp, night stand, chair, chest of drawers and a closet. LPA observed bedroom five has an exit and observed the alarm alert signal was properly working when exited to the backyard.

LPA observed the locked laundry room and the door leading to the garage was locked. LPA observed a hallway closet which contained additional linens and PPE supply. The two bathrooms contained wash your hands sign, hand soap, paper towels, slip resistant mat and a trash can. The Administrator tested the smoke/carbon monoxide detectors which were properly working at 10:30 am. There are no deficiencies to report at this time. Exit interview conducted, and a copy of the report was given to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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