<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610591
Report Date: 11/20/2024
Date Signed: 11/20/2024 01:21:48 PM

Document Has Been Signed on 11/20/2024 01:21 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:AMEN SENIOR HOMEFACILITY NUMBER:
197610591
ADMINISTRATOR/
DIRECTOR:		MARTIN, DENISEFACILITY TYPE:
740
ADDRESS:43903 KENNSINGTON PLTELEPHONE:
(301) 323-3115
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 0DATE:
11/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Denise MartinTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 9:15 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the administrator, Denise Martin. This is new application for a Residential Care Facility for Elderly (RCFE). A fire clearance was approved on 06/26/2024, for six (6) non-ambulatory residents for a total capacity of six (6).

A tour of the physical plant was initiated at approximately 09:25 a.m. and the following was observed:

COMMON AREAS: These included living room and a dining room. The living room was equipped with furniture, a television, couches. There is a fireplace secured with a screen in the living room. The dining area has a dining room table to accommodate six (6) residents, a sofa and a piano. There were no visible immediate hazards. The facility has hard wired and battery operated smoke detectors through out the facility. At 9:38 a.m., smoke alarms and carbon monoxide detectors were tested and observed operational.

OFFICE: There is an office space located in the living room. Resident and staff records will be maintained locked in a filing cabinet.

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave, and dishwasher. There is an adequate supply of seven (7) days nonperishable food. There is an adequate amount of table ware for the capacity of the facility. Knives and other sharps will be locked in a kitchen cabinet. Cleaning products and Chemicals are kept locked under the kitchen sink, inaccessible to residents in care. The fire extinguisher was located by the kitchen and in the living room.



BEDROOMS: The facility has four (4) bedrooms. The applicant furnished all clients' bedrooms with beds, night stands, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. (Continue on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMEN SENIOR HOME
FACILITY NUMBER: 197610591
VISIT DATE: 11/20/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LAUNDRY ROOM/GARAGE: The washer and dryer is located in the laundry room accessible to residents. LPA observed all chemicals are kept locked in cabinets above the washer and dryer. The garage is accessible to from the laundry room. The garage is used for storage of the emergency food, water and facility supplies.

BATHROOMS: The facility has two (2) bathrooms and were observed to have the proper fixtures, grab bars, non-skid mats, and trash cans with closed lids. The hot water delivered in the bathroom was measured at 1:10 p.m. to be at 119.2 degrees, within regulation.

MEDICATIONS: The medications be centrally stored in on of the laundry room cabinet locked, inaccessible to residents. Facility has a First-aid kit and current manual.



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 backyard furniture to accommodate six (6) residents. There is no body of water.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also conducted with the administrator/applicant representative.

Pre-Licensing is complete and this facility has no deficiencies. This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.


Exit interview conducted and copy of this report signed and delivered to the Administrator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2