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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201925
Report Date: 04/26/2022
Date Signed: 04/26/2022 04:43:42 PM

Document Has Been Signed on 04/26/2022 04:43 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LARC ADULT HOME IFACILITY NUMBER:
191201925
ADMINISTRATOR:STURKEY, KATHYFACILITY TYPE:
735
ADDRESS:29898 N BOUQUET CANYON RDTELEPHONE:
(661) 296-8636
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY: 72CENSUS: 63DATE:
04/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Chris BratzelTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Abeye Duguma conducted unannounced case management visit to the facility. At 1:15pm LPA met with the administrator, Chris Bratzel, explained the purpose of this visit and conducted a physical plant tour.

On 10/31/2021, Client #1 (C1) threw a chair at a Staff #1 (S1), damaged the refrigerator and yelled at S1 using offensive language. S1 asked C1 to calm down and asked for C1 to step outside. C1 eventually calmed down.

On 01/05/2022, C1 was in the living room and mocked Client #2 (C2), C2 asked said C1 to stop and C1 continued mocking. S1 overheard and intervened. C1 then pushed/shoved S1 into the stove. S1 asked C1 to step outside and C1 later calmed down.

On 04/04/2022, Staff #2 (S2) was in the kitchen and C2 said something to C1 and C1 began yelling offensively and walking towards C2. S2 sees that C1 is very upset and begins walking towards C1, C1 then throws a nearby chair at S2 and grabs and pinned C2 against the wall in a corner. S2 intervenes, redirects C1 and asks that C1 step outside. C1 later calms down.

On 04/24/2022, C1 was yelling offensive language at Staff #3 (S3), picked up a chair, threw it at S3 and missed. S3 tried to back away and de-escalate, but it was then that C1 grabbed S3 by the shirt and, using the outer forearm, pinned S3 up against the wall. Staff #4 (S4) heard the commotion from the adjacent villa, went to see what was happening and saw the thrown chair on the floor. S4 then asked C1 to step out and calm down.

During this visit at 1:45pm LPA spoke with the Administrator. Interviews revealed that staff were present during all incidents and intervened to de-escalate.


(Cont. on LIC809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LARC ADULT HOME I
FACILITY NUMBER: 191201925
VISIT DATE: 04/26/2022
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At the time of this visit at 2:50pm LPA inspected the facility, specifically the area where the incidents took place. In addition, at 3:20pm LPA requested facility records. LPA will return at later time to complete the case management visit involving the verbal and physical altercations between C1 and C2, C1 and S1, C1 and S2, and C1 and S3.

Exit interview was conducted and a copy of report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
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