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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610472
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:12:04 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/15/2025 02:12 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:AV RCFE, OLDFIELDFACILITY NUMBER:
197610472
ADMINISTRATOR/
DIRECTOR:		DE GUZMAN,FERNANDO JR.FACILITY TYPE:
740
ADDRESS:839 EAST OLDFIELD STREETTELEPHONE:
(661) 418-0425
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 0DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Fernando De GuzmanTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 01/15/2025, Licensing Program Analyst (LPA) Lorena Casillas conducted an announced annual visit to this facility and met with the Administrator Fernando De Guzman. The facility has a fire clearance for five (5) non-ambulatory residents and one (1) bedridden resident.

LPA arrived at 9:30 am, there was no one at the facility. LPA called and spoke to Administrator who stated that they were on their way to the facility. Administrator arrived shortly after. LPA spoke to Administrator and explained the reason for the visit. Entrance interview conducted.

While LPA was waiting for Administrator LPA noticed a smell of natural gas. Upon entry to the home LPA noticed that there was a strong smell of natural gas. LPA and Administrator exited the building and emergency services were called. Southern California Gas company and the Fire Department arrived shortly after, found there to be a leak in a valve on the boiler located in the garage. This will be immediately repaired. Once the home was cleared LPA and Administrator resumed the annual visit.

At 11:30 am LPA began the facility tour with the Administrator, the following was observed. The facility has no residents currently residing therefore the tool kit was not used during this visit.

Common area: The living room contained comfortable seating. The family room contained comfortable seating and games. The room temperature was at a comfortable 68°F. Smoke detectors and carbon monoxide detector were tested at 12:00 pm and were observed to be operational. The dining area was neat and clean with sufficient seating to accommodate all residents.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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: AV RCFE, OLDFIELD
FACILITY NUMBER: 197610472
VISIT DATE: 01/15/2025
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Kitchen: The facility has a seven-day supply of non-perishable food and will have a two-day supply of perishable foods when residents are acquired. There are two (2) fire extinguishers, one is located in the kitchen and the other in a hallway, both were full. Appliances in the kitchen appeared to be functional. The medication will be locked in a medication cabinet which is stored on the kitchen counter. The knives are located in a locked kitchen drawer. The kitchen appeared to be clean of clutter and free of pests.

Bedrooms: There are three (3) bedrooms for resident use, which contained beds, a mattress on each bed, linens, night stand, lamp, a chair, chest of drawers, and a closet. All window screens were in good repair.

Bathrooms: There are two (2) bathrooms which contained hand soap, paper towels, grab bars, slip resistant mats and a trash can with a lid. The water temperature was tested at 12:10 pm and was within regulation between 105°F and 120°F.

Laundry/Garage: The washer and dryer were in the garage and appeared to be functional and in good repair. There is a hallway closet that was locked and contained cleaning solutions. A hallway cabinet contained linens and personal hygiene items. LPA observed additional stored items in the garage.

Surrounding grounds: The backyard contained comfortable seating. The side gate leading from the backyard to the front yard was not locked. Passageways were clear of obstructions. LPA observed egress delayed alarms throughout the facility, and they were observed to be functional.

Resident and staff files: No current residents or staff, files were not reviewed.

Medication: There are no medications as there are no residents.

Resident and Staff interviews: No interviews conducted as there are no residents or staff.

Administrative: All fees are current.

No citations issued. Exit interview conducted. Copy of report provided to Administrator.

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

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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