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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610348
Report Date: 01/25/2023
Date Signed: 01/25/2023 11:32:46 AM

Document Has Been Signed on 01/25/2023 11:32 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:CLUB RANCHO MANOR INCFACILITY NUMBER:
197610348
ADMINISTRATOR:DE LIMA, MARY ANNFACILITY TYPE:
740
ADDRESS:3618 CLUB RANCHO DRIVETELEPHONE:
(323) 680-0844
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 0DATE:
01/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mary Ann DeLimaTIME COMPLETED:
11:30 AM
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LPA Spaeth conducted an announced pre-licensing visit. LPA was greeted by Administrator and LPA observed the COVID signs on the front door. LPA's temperature was recorded and LPA observed the sign in station which included thermometer, hand sanitizer, and sign in sheet. LPA conducted the COMP III presentation at 9:15 am until 9:45 am. LPA and Administrator began the tour at 9:45 am until 10:05 am.

Common areas - LPA observed a sitting room with comfortable seating, games, magazines, and a music area within the room. Administrator stated this room is available for residents to participate in group activities, a location to read, or enjoy music. LPA observed the living room contained comfortable seating and a television.

Kitchen/Dining Room - The kitchen and dining room are combined and contained a dining room table and chairs. LPA observed a seven day supply of non-perishable food and a two day supply of perishable food items. The locked cabinet beneath the kitchen sink contained cleaning solutions. Wash your hands sign and hand soap are located at the sink. The medications and client records will be locked in a kitchen cabinet. LPA also observed the first aid kit which contained all the required first aid products (scissors, tweezers, etc). The knives were locked in a kitchen drawer. A fire extinguisher was located in the kitchen.

Backyard area - LPA observed shaded seating area in the backyard and the side gate leading from the backyard to the front yard was not locked. LPA also observed the egress security device was working when exiting to the backyard.

Bedrooms- LPA observed there are five residents’ rooms which contained bed, linens, closet, lamp, night stand and chest of drawers. Each room contains exit doors to the facility exterior area. LPA observed the egress alarm devices were operational.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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: CLUB RANCHO MANOR INC
FACILITY NUMBER: 197610348
VISIT DATE: 01/25/2023
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Bathrooms - LPA observed all three bathrooms contained wash your hands sign, hand soap, paper towels, slip resistant mats in the shower/bathtub and a trash can. LPA also observed an adequate supply of hygiene items. At 9:57 am, LPA tested the water temperature in Bathroom One and the temperature was 117.5 degrees F.

Hallway - LPA observed additional linens were stored in a hallway cabinet. LPA also observed a fire extinguisher located in the hallway area. The carbon monoxide monitor was located within this area.

Laundry Room - LPA observed the washer and dryer in the room. A locked cabinet contained the laundry soap.
Garage - An egress security device was properly installed when exiting to the garage.


Administrator confirmed the facility phone number is 661-234-4498. LPA observed all the required signs were posted within the facility such as the facility sketch, Let Us No and Ombudsman sign. The activities calendar and facility menu were also posted within the common area of the facility. LPA and Administrator tested the smoke detectors at 10:35 am and the alarms were properly working.

LPA did not observe any health or safety issues during LPA's tour of the facility. Exit interview was conducted and a copy of the signed report was given to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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