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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603477
Report Date: 09/10/2023
Date Signed: 09/10/2023 01:09:41 PM

Document Has Been Signed on 09/10/2023 01:09 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
WOODLAND HILLS S.ASC, 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:
09/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Luis Bru Jr. - AdministratorTIME COMPLETED:
01:15 PM
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A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Luis Bru Jr. Purpose of visit was stated. This is a North Los Angeles Regional vendored facility level 3.

A tour of the physical plant was conducted at 10:08 PM and the following was noted:

The facility has two (two) gates leading to the main door. The only entrance being utilized is the main front door, there is a sign at the main door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan.

Signs to wear a mask 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. All trash cans were observed to be with cover. The facility has a designated visitors' area at the front and backyard. The facility has sufficient stock of PPE in the storage room.

Facility has four (4) bedrooms and two (2) bathrooms. One (1) bedroom and one (1) bathroom is designated for staff use. There is no body of water in the facility.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 105.9°F and within the required range.

(continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVYN LANE FAMILY HOME
FACILITY NUMBER: 197603477
VISIT DATE: 09/10/2023
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living, dining and family rooms furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the garage. Knives and sharps were kept in a locked drawer.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat was set 78.0°F and observed to be within the required range.
Fire extinguisher. There is a fire extinguisher located in the kitchen. Extinguishers were observed to be current and last inspected on 06/09/23. Smoke alarms are hardwired. Carbon monoxide and smoke alarms were tested and observed to be operable.

The garage is currently being used as tools, supplies and used equipment storage. Laundry area is located adjacent to the dining area leading to the garage. Laundry detergents and other cleaning agents and toxins are kept locked in the cabinet in the laundry area. Medication was observed to be inaccessible and stored in a secured medication cabinet in the main hallway entrance. There is a complete First Aid kit in the medication cabinet.

Client records. All of four (4) clients records were reviewed. Clients record appeared to be complete and current. Staff records were also reviewed. Four (4) staff records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 06/09/23. Required posting observed in facility (complaint hot line poster, personal rights, etc).



There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2023
LIC809 (FAS) - (06/04)
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