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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610644
Report Date: 08/19/2024
Date Signed: 08/19/2024 11:59:51 AM

Document Has Been Signed on 08/19/2024 11:59 AM - 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:TOUCH OF AN ANGEL LANCASTERFACILITY NUMBER:
197610644
ADMINISTRATOR/
DIRECTOR:		THOMAS, STACYFACILITY TYPE:
740
ADDRESS:2647 WEST AVENUE K4TELEPHONE:
(323) 385-8298
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 3DATE:
08/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Stacey Thomas (Administrator)TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the administrator Stacey Thomas. The applicant is "TOUCH OF AN ANGEL LANCASTER LLC" and this is a "Change of Ownership" application. A fire clearance was approved on 07/02/24 for four (4) ambulatory residents, and room #3 approved for one (1) non-ambulatory, and (1) bedridden for a total capacity of 6. Facility has a Hospice waiver approved for three (3) residents.

The facility is a two story home with the second floor designated for live-in staff only. The facility has a total of three (3) bedrooms and two (2) bathrooms for resident use. A tour of the physical plant was initiated at approximately 10:00 a.m. and the following was observed:

KITCHEN: The facility has a kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of perishable and nonperishable food; properly stored. LPA observed a fire extinguisher, fully charged.

BEDROOMS: There are three (3) bedrooms designated for residents' use: all three (3) bedroom are shared. The bedrooms are furnished with beds, night stand, chairs, dressers, bedding and linens. The bedrooms have sufficient lighting and storage.

BATHROOMS: The facility has two (2) shared bathrooms for clients' use. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at 117°F.
LAUNDRY ROOM: The laundry room is located in the garage accessible to residents. Laundry detergents and other cleaning agents were locked in a cabinet inside the garage inaccessible to residents in care. The cleaning supply cabinet was observed to be locked during visit. (continue to LIC 809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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: TOUCH OF AN ANGEL LANCASTER
FACILITY NUMBER: 197610644
VISIT DATE: 08/19/2024
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COMMON AREAS: These included the living area, sitting area and the dining area. Living area and sitting area are furnished with chairs, sofas and side tables. The living room area was furnished with a television, a coffee table and sofas sit the capacity of the facility. There were no visible immediate hazards. There is a working telephone line and internet accessible to residents. Smoke and carbon monoxide alarms were tested and observed to be operable.

MEDICATIONS: The medication cabinet is located in the kitchen and has a locking mechanism. A complete first aid kit is located in the kitchen.

Staff/Resident Records: Staff and resident records are kept in the filing cabinet. LPA and applicant discussed thee (3) of three (3) resident records. LPA shared best practices and forms required in residents' files.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a table and chairs with an umbrella to provide shade for residents. A shed that was observed locked used for storage.

GARAGE: The garage stores extra facility supplies and cleaning supplies as well as detergents that were observed locked in cabinets.

Component III was conducted with the applicant/administrator.

This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved.

Exit interview conducted. Copy of this report issued.

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

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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