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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603477
Report Date: 08/19/2022
Date Signed: 08/19/2022 01:07:31 PM

Document Has Been Signed on 08/19/2022 01:07 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:DEVYN LANE FAMILY HOMEFACILITY NUMBER:
197603477
ADMINISTRATOR:LUIS BRU JR.FACILITY TYPE:
735
ADDRESS:43709 DEVYN LANETELEPHONE:
(661) 946-1613
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Luis Bru Jr, AdministratorTIME COMPLETED:
01:15 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
Licensing Program Analyst (LPA) Shira Stamps met with Administrator Luis Bru for an unannounced one (1) year Required visit for this facility.

LPA arrived at 12:15pm and was greeted by the Administrator. All clients were at their day programs at the time of inspection. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed the facility mitigation plan (approved on 03/13/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the Administrator and asked all infection control questions. LPA was signed-in and sanitizer was available.

A tour of the physical plant was conducted with Administrator at 12:30 pm. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. One (1) bathroom and one(1) bedroom is designated for staff use only and the facility has awake staff at night. The facility is Fire Cleared for four (4) ambulatory.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client.

Bathrooms
At 12:35 pm LPA observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested and measured within regulation at 106.7 degrees F.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVYN LANE FAMILY HOME
FACILITY NUMBER: 197603477
VISIT DATE: 08/19/2022
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/Garage
LPA observed no chemicals/hazardous items in the laundry room. LPA observed the locked garage to be attached to the facility and the only entry was through the laundry room. The garage is currently being used for extra storage.

Food Inspection
LPA conducted tour at the kitchen around 12:30 pm and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests.

Hallway Closet
LPA observed all knives and sharp object being locked and inaccessible to clients in care. LPA observed the medications, cleaning supplies, 1st aid kit, and client and staff files locked in the hallway closet.

Physical environment
LPA toured the outside area of the facility at 12:40 pm. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature at 82°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 12:45 pm. There is one (1) fire extinguishers located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 06/17/22.

Administrative: LPA collected the LIC.500 and client roster. Annual fee is current.

An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2