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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610542
Report Date: 12/17/2024
Date Signed: 12/17/2024 12:11:46 PM

Document Has Been Signed on 12/17/2024 12:11 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASANOVA CARE HOMEFACILITY NUMBER:
197610542
ADMINISTRATOR/
DIRECTOR:		FLORES, RODERICKFACILITY TYPE:
740
ADDRESS:44315 CASA NOVA DR.TELEPHONE:
(661) 206-8026
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 3DATE:
12/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Roderick Flores and Michael MendozaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 12/17/2024 at 9:00 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the facility Administrator, Roderick Flores and Michael Mendoza the Applicant/Licensee representative. This is a Change of Ownership Application from facility #197610238 to operate a Residential Care Facility for the Elderly (RCFE). A Change in Ownership (CHOW) Application to operate an RCFE was received by Community Care Licensing (CCL) on 12/13/2023. A fire clearance was approved on 03/20/2024, for six (6) Non-Ambulatory residents for a total capacity of six (6).

A tour of the physical plant was initiated at approximately 9:10 a.m., and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave and sink. There were adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food, properly stored. LPA observed a sufficient amount dining ware to accommodate the maximum capacity of six (6) residents. Knives and other sharps were observed locked in a kitchen cabinet.

BEDROOMS: The facility has five (5) bedrooms, and one (1) is shared. All resident bedrooms are furnished with beds, night stands, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. Additional linen is available in the closet located in the hallway.

BATHROOMS: The facility has two (2) bathrooms. Both bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash can with closed lids.

The smoke alarms and detectors are hard wired and inter-connected, they were tested at 9:20 a.m. and were observed operational. The facility has one (1) fire extinguisher that was purchased on 6/06/2024 and is located by the kitchen. The facility has two carbon monoxide detectors that were observed operational. (Continue to LIC809-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
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)
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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CASANOVA CARE HOME
FACILITY NUMBER: 197610542
VISIT DATE: 12/17/2024
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COMMON AREAS: These included living room and a dining room. The living room was equipped with furniture, a television, tables and chairs. There is a fireplace properly secured with a screen. The dining area has a dining room table to accommodate six (6) clients. There were no visible immediate hazards.

LAUNDRY ROOM/GARAGE: The washer and dryer is located in a separate room that leads to the garage and designated office. Laundry chemicals are also kept in the laundry room which is kept locked and inaccessible to residents. The garage is used as extra storage for the facility. There is a deep freezer and second refrigerator in the garage for additional food items.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a covered patio and outdoor furniture to accommodate six (6) clients. There is no body of water.

MEDICATIONS: The medications are kept locked in a cabinet located in the kitchen. LPA observed Centrally Stored Medication and Destruction Records for each resident. LPA discussed with the administrator and the licensee the importance of providing residents with medications that are prescribed to residents by an authorized physician. LPA observed a fully stocked First-aid kit in the linen closet.

Resident Files/Staff Files: LPA conducted a file review of all resident records to ensure compliance of licensing forms. Clients’ files are complete and kept locked in a filing cabinet located in the office. LPA reminded administrator and licensee residents diagnosed with Dementia require an annual medical assessment/Physician's Report completed. Staff files are also kept in a locked cabinet located in the office. LPA discussed staff files with the administrator and licensee and reminded them to ensure compliance by having complete documents and up to date training.

In addition to the Pre-Licensing inspection, a Component III Power Point presentation was also conducted with the administrator and licensee present. Pre-Licensing is complete and this facility has no deficiencies. CAB will be advised.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
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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