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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610527
Report Date: 01/31/2025
Date Signed: 01/31/2025 04:00:12 PM

Document Has Been Signed on 01/31/2025 04:00 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/
DIRECTOR:		FRANCISCO, CLAIRE JITH M.FACILITY TYPE:
740
ADDRESS:39430 11 STREET WESTTELEPHONE:
(818) 427-3257
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 3DATE:
01/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Claire FranciscoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregivers. LPA Spaeth stated the purpose of the visit was to conduct an annual inspection. The caregiver confirmed there are three residents living in the facility. The Administrator, Claire Francisco arrived at 10:30 am.

The facility is licensed for six non-ambulatory residents in rooms 1, 3, 4 and 5 of which one bedridden may be bedridden in bedroom 5. Room 2 is the designated staff room.

LPA Spaeth reviewed the residents' files at 11:00 am until 11:20 am.

LPA toured the facility at 11:20 am until 12:00 pm and 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 were 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.

Backyard - The backyard contained a shaded area with comfortable seating. The side gate leading from the backyard to the front yard was not locked.
Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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: 01/31/2025
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Bedrooms –LPA Spaeth observed 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 11:50 am 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.

LPA reviewed staff records at 11:50 am until 12:10 pm. and checked the residents' medications at 12:10 pm until 12:20 pm.

The smoke and carbon monoxide detectors were tested at 12:15 pm and were operable. The facility was clean and appears to be in good repair.

There are no deficiencies to report at this time. Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC809 (FAS) - (06/04)
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