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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610419
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:38:59 PM

Document Has Been Signed on 05/05/2023 03:38 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:ALL STAR CARE INCFACILITY NUMBER:
197610419
ADMINISTRATOR:DARABEDYAN, IVETAFACILITY TYPE:
740
ADDRESS:36240 52 ST EASTTELEPHONE:
(818) 624-6006
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 0DATE:
05/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Iveta DarabeyanTIME COMPLETED:
12:30 PM
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On 5/04/2023, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with applicant Iveta Darabedyan. This is an initial application for an RCFE. A fire clearance dated 4/20/2023 was received for five (5) non-ambulatory residents and one (1) bedridden resident. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Divisions 6.

LPA conducted the COMP III presentation from 11:10 am until 11:55 am.

Today’s site visit consisted of LPA touring the physical plant inside and outside. The tour began at 9:45 am and concluded at 10:30 am. LPA observed the following:

Kitchen Area – The facility has a fire extinguisher located in the kitchen. There is a functioning telephone on the premises and the facility phone number is 661-526-7021. The knives are safely locked in a kitchen cabinet. The facility PPE is stored in a closet near the kitchen. The medications will be locked in a kitchen cabinet. The first aide kit was locked in the same cabinet. The pantry contained a seven-day supply of non-perishable foods and the refrigerator contained fruits and vegetables. LPA observed the facility menu posted in the kitchen.

Dining Room – LPA observed a dining room table along with comfortable chairs located in the room.

Office – Games were stored in the office. The emergency exit plan/sketch is posted within the room. The resident and staff records will be locked in a two-drawer file cabinet.

Living Room – The living room is furnished with comfortable seating and a television.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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: ALL STAR CARE INC
FACILITY NUMBER: 197610419
VISIT DATE: 05/05/2023
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Bedrooms – there are four (4) resident bedrooms which contain bed, linens, chest of drawers, lamp, night stand, and a chair. Room 4 will accommodate two residents and Room 5 is designated as a bedridden room. The facility also contains a staff bedroom.

Door Alarms – There are four exit doors and LPA heard the egress alarms connected to each door.

Bathrooms – There are three (3) bathrooms in the facility. One bathroom is located in Room 5, the staff bathroom and bathroom 3 are located in a hallway. The bathrooms contained, hand soap, paper towels and covered trash cans. LPA tested the water temperature in the resident bathroom at 9:46 am. The water temperature was 113.7 degrees F.

Hallway Cabinets – Clean linens are stored in a hallway cabinet. The residents’ personal hygiene items are safely locked in the hallway cabinet.

Laundry Room –The laundry room is locked and contained the laundry detergent and cleaning products.

Smoke/Carbon Monoxide Detectors- The smoke/carbon monoxide detectors were tested at 10:25 am and were operational.

Outdoor area – There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced and there are no bodies of water. The gate leading from the backyard to the front yard is not locked.

There are no issues to report at this time. This report will be forwarded to the Centralized Application Bureau (CAB). The Applicant will be notified by the CAB Analyst when the facility license has been approved. Exit interview was conducted and a copy of the report was signed and given to the Applicant.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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