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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201925
Report Date: 01/31/2023
Date Signed: 01/31/2023 03:38:39 PM

Document Has Been Signed on 01/31/2023 03:38 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: DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Kathleen SturkeyTIME COMPLETED:
02:29 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with the Executive Director, Kathleen Sturkey, for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:00pm and the following was noted:
There are multiple entrances being utilized at the facility, each with its own sign-in station, there are required posters posted at the main doors. Screening areas are located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The campus has multiple shaded areas for residents and visitors. The facility has sufficient stock of PPE in a storage closets located near the entrances. The facility has a total of forty-five (45) bedrooms, of which nine (09) are for staff and twenty-seven (27) bathrooms for both residents and staff. The facility is licensed for 72 residents. The facility has a locked and fenced swimming pool on the property. Laundry detergents, cleaning agents and other toxins are stored in a locked laundry room. Kitchen area is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen cabinets inaccessible to residents. Living and dining room furniture were also checked. The living rooms are neat and clean along with the dining room. The facility maintains an average comfortable temperature of 71°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located in the kitchens and hallways observed to be full and last inspected on 01/18/2023. Staff rooms were observed to be locked. No medications are observed in staff rooms.

(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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: 01/31/2023
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The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathrooms were checked for cleanliness and proper operations. The hot water temperature was measured an average 112.8°F. Towels and washcloths are not shared. There was enough clean linen available in storage closets located near the front entrance. LPA observed medications and first aid kits to be locked and inaccessible to residents, located in the kitchen.
Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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