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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610527
Report Date: 03/08/2024
Date Signed: 03/08/2024 04:05:17 PM

Document Has Been Signed on 03/08/2024 04:05 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CLAIRE'S VILLAFACILITY NUMBER:
197610527
ADMINISTRATOR:FRANCISCO, CLAIRE JITH M.FACILITY TYPE:
740
ADDRESS:39430 11 STREET WESTTELEPHONE:
(818) 427-3257
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 0DATE:
03/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Claire FranciscoTIME COMPLETED:
03:30 PM
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On 3/08/2024, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with the Licensee. This is a new application and a fire clearance dated 12/07/2023 was received for five (5) non-ambulatory residents and one (1) bedridden resident. The facility phone number is 661-526-7051.

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. Component III was conducted with the applicant from 2:10 pm until 3:10 pm.

Today’s site visit consisted of LPA touring the physical plant inside and outside from 3:10 pm until 3:40 pm LPA Spaeth observed the following:

Living Room – The room contained comfortable seating and a television.

Kitchen/Dining Room - The facility contained a seven-day supply of non-perishable food and a two-day supply of perishable foods. The knives were locked in a kitchen cabinet. The cleaning solutions were locked underneath the kitchen sink. The medications will be locked in a kitchen cabinet. LPA observed the first aid kit was securely locked in the kitchen. Cleaning supplies were also locked in a kitchen cabinet. A fire extinguisher is also located in the kitchen. Appliances in the kitchen appeared to be functional. The dining room area contained a dining room table and chairs.

Continued - 809C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CLAIRE'S VILLA
FACILITY NUMBER: 197610527
VISIT DATE: 03/08/2024
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Backyard - The backyard contained a shaded area with comfortable seating. The side gate leading from the backyard to the front yard was not locked.

Bedrooms – Bedroom one is designated for two non-ambulatory residents, bedroom two designated for staff only, bedroom three to house one non-ambulatory resident, bedroom four to house one non-ambulatory resident, bedroom five to house one bedridden, and one non-ambulatory resident. The bedrooms were furnished with a bed, linens, night stand, lamp, chest of drawers, a chair and a closet.

Bathrooms- There are three bathrooms which contained hand soap, grab bars, non-skid mats, paper towels, and trash can. The water temperature was recorded at 3:50 pm and was 108.0 degrees F.

Hallway - The hallway cabinet contained clean linens.

Laundry Room – the laundry room was locked and contained the washer and dryer.

Garage- LPA observed there were no safety issues.

Egress- LPA observed the egress system were properly working at each exit door.

The smoke and carbon monoxide detectors were tested at 2:15 pm and were operable. The facility was clean and appears to be in good repair.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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