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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610457
Report Date: 12/17/2024
Date Signed: 12/17/2024 11:08:45 AM

Document Has Been Signed on 12/17/2024 11:08 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KEEPSAKE CAREFACILITY NUMBER:
197610457
ADMINISTRATOR/
DIRECTOR:		DANIELS, TEJEIRAFACILITY TYPE:
740
ADDRESS:43528 32ND ST ETELEPHONE:
(909) 771-9565
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Tijeira DanielsTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Tejeira Daniels for an unannounced one (1) year Required visit for this facility. LPA arrived at 9:30 am, there was no one in the facility. LPA called Administrator who stated that there were no residents yet, LPA explained the reason for the visit and Administrator stated that they would be arriving soon. Administrator arrived shortly after.

The facility is fire cleared for two (2) non-ambulatory residents and two (2) ambulatory residents for a total capacity of four (4). There were no residents observed in the facility.

The tool kit was not used, as there are no residents in the facility yet. A tour of the physical plant was initiated at approximately 10:30 am and the following was observed:

KITCHEN: LPA conducted a tour of the kitchen at 10:40 am and observed there to be sufficient stock seven-day non-perishables foods, perishable foods will be purchased when residents are obtained. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible to residents in the staff office located in an area of the living room. The medications will be stored in a locked cabinet in the kitchen.

BEDROOMS: There are three (3) bedrooms designated for resident use. Two (2) rooms are designated as private rooms. One (1) bedroom will be shared. The bedrooms have beds, nightstands, chairs, dressers, 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 115.1 degrees F.

Continued on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 12/17/2024
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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 and were tested at 10:50 am. The carbon monoxide detector is functional and installed in the entrance, also tested at 10:55 am. The facility has one fire extinguisher that was fully charged on 09/27/2023, LPA advised Administrator that although the fire extinguisher is full, it does need to be serviced or replaced. Administrator will send LPA proof of service as soon as possible. It is located by the dining room and living room area.

LAUNDRY ROOM: The laundry room is locked and located adjacent to the kitchen. Cleaning detergents and supplies are locked and inaccessible.

Physical environment: LPA toured the outside area of the facility at 11:00 am. The driveway, passageways and entrance to the home were 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 and has a covered porch for shade. There is no swimming pool or bodies of water.

Garage: LPA observed the garage to be attached to the facility and currently being used for extra storage. There are no additional refrigerators or freezers.

Administrative: Administrator Certificate, and Liability Insurance was emailed to LPA. Annual fees are current.

Client & Staff Files: LPA did conducted a file review as there are no residents or staff.

Medications: LPA did not review medications, as there are no residents.

Staff/Resident Interviews: LPA did not interview staff or residents.

No citations issued. Exit interviewed conducted and a copy of the report was provided to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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