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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610457
Report Date: 01/05/2024
Date Signed: 01/05/2024 02:13:39 PM

Document Has Been Signed on 01/05/2024 02:13 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KEEPSAKE CAREFACILITY NUMBER:
197610457
ADMINISTRATOR:DANIELS, TEJEIRAFACILITY TYPE:
740
ADDRESS:43528 32ND ST ETELEPHONE:
(990) 771-9565
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 0DATE:
01/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tejeira DanielsTIME COMPLETED:
01:00 PM
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On 01/05/2024 at 10:00 am, Licensing Program Analyst (LPA) Lorena Casillas conducted an announced Pre-Licensing Inspection with the Administrator Tejeira Daniels and Licensee Porscha Daniels. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on October 17, 2023. A fire clearance was approved on October 18, 2023, for two (2) non-ambulatory residents and two (2) ambulatory residents for a total capacity of four (4). The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 10:15 am until 10:58 am with Administrator and Licensee.

A tour of the physical plant was initiated at approximately 11:00 am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of four (4). Knives will be locked in a cabinet in the office area.

BEDROOMS: There are three (3) bedrooms designated for resident use. Two (2) rooms are designated to be private rooms. One (1) bedroom will be shared. Bedroom #1 has a direct exit and will be for Non-Ambulatory residents. The applicant furnished the resident bedrooms with beds, nightstand, chairs, dresser, bedding and linen. All rooms had sufficient lighting.

BATHROOMS: The facility has two (2) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid mats. The hot water delivered in the bathrooms measured 114 degrees F.

Continued on 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KEEPSAKE CARE
FACILITY NUMBER: 197610457
VISIT DATE: 01/05/2024
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COMMON AREAS: These included the living room and dining room areas, which were equipped with living room furniture, a television, tables, and chairs. The dining room table is large enough to accommodate up to four (4) residents. There is a fireplace with a glass barrier. No fireplace tools or fixtures present. There were no visible immediate hazards. The smoke alarms are hard wired and inter-connected. The carbon monoxide detector is functional and installed in the entrance. The facility has one fire extinguisher that was fully charged on 09/27/2023. It is located by the dining room and living room area.

LAUNDRY ROOM: The laundry room is located adjacent to the kitchen. Cleaning detergents and supplies are locked in a cabinet in the living room area.

MEDICATIONS: Medications will be stored in a locked cabinet in the kitchen.

STAFF/RESIDENT RECORDS: Staff and resident records will be stored in a locked cabinet, located in the living room. The applicant was advised to ensure that resident and staff records will be accessible to the licensing agency upon request or during inspection. Facility will have awake staff.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and backyard furniture. The facility backyard has sufficient yard space to accommodate outdoor activities. There is no swimming pool or bodies of water.

Exit Interview was conducted, and a copy of this report was given to applicant.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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