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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610350
Report Date: 03/01/2023
Date Signed: 03/01/2023 01:00:19 PM

Document Has Been Signed on 03/01/2023 01:00 PM - 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:PURE HEART CARE LIVINGFACILITY NUMBER:
197610350
ADMINISTRATOR:DELA CRUZ, CHRYSEL S.FACILITY TYPE:
740
ADDRESS:45731 TRAFALGAR DRIVETELEPHONE:
(661) 579-9637
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 0DATE:
03/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Chrysel Dela CruzTIME COMPLETED:
01:10 PM
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On 3/1/2023, Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an announced Pre-licensing inspection. Upon arrival LPA met with applicant Chryshel Dela Cruz. The facility will be licensed as aResidential Care Facility for the Elderly. Facility is a single-story house with four (4) bedrooms and two (2) bathrooms. Facility has been approved for a capacity for six (6) clients.

The physical plant was toured inside and out at 10: 45 a.m. and LPA observed the following:

Common Area: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The facility maintains a comfortable temperature at 73 degrees Fahrenheit. The air conditioner is operational. No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector are dual functioning and hard wired throughout the facility. There are various fire extinguishers which were observed to be fully charged. Facility maintains an operational telephone.

Kitchen Area: LPA observed the kitchen area to be in good repair and sanitary. A start up amount of perishable and non-perishable foods were observed. A cabinet with a lock will be used to keep sharps locked and inaccessible to residents in care. Medication will also be centrally stored and locked in a kitchen cabinet. Trash containers have tight-fitting lids.

Bedrooms: Facility has four (4) bedrooms, three (3) of which will be for residents and one (1) for staff. All bedrooms were toured and were observed with the appropriate furniture and bedding and sufficient lighting was observed. (cont. on LIC809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2023
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: PURE HEART CARE LIVING
FACILITY NUMBER: 197610350
VISIT DATE: 03/01/2023
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Bathrooms: Facility has two (2) bathrooms. Bathrooms were toured and were observed to be clean. LPA observed sufficient towels and wash cloths for residents. Trash cans with lids were observed.

Garage: Garage was toured. Garage door is accessible through the hall and is kept locked and inaccessible to clients. Garage area will be used as a storage area along with PPE supplies.

Outside: LPA observed a shaded area for residents. No patio furniture was observed due to the current weather conditions, but applicant will provide a picture when it is set up no later than 3/8/2023. There are no bodies of water.

Administrative: LPA discussed preplacement staffing, training, customer service, inspection authority, reporting requirements (mandated reporter), records, citations, criminal record clearance, civil penalties, activities, and expectations to follow all rules and regulations. Applicant/Administrator has completed component III.

Upon completion of the following items, this report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Report has been signed and delivered. Exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC809 (FAS) - (06/04)
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