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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201925
Report Date: 02/11/2024
Date Signed: 02/11/2024 12:47:54 PM

Document Has Been Signed on 02/11/2024 12:47 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:
02/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Tammy Doyle, Resident AdministratorTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Abeye Duguma met with Tammy Doyle for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 08:00 AM and the following was noted:

There are multiple entrance being utilized at the facility. 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 is currently occupying sixty-six (66) residents.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility's swimming pool is fenced and locked. Laundry detergents, cleaning agents and other toxins are locked away.

Kitchens are sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

The living and dining rooms are neat and clean. The facility maintains a comfortable temperature at 73°F. The smoke and carbon monoxide detectors are hardwired, interconnected and checked periodically. Fire extinguishers are located throughout the facility, observed to be full and last inspected 02/15/2023.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LARC ADULT HOME I
FACILITY NUMBER: 191201925
VISIT DATE: 02/11/2024
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The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 109.9°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

LPA observed medication and first aid kit to be locked and inaccessible to residents.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2024
LIC809 (FAS) - (06/04)
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