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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603477
Report Date: 08/16/2024
Date Signed: 08/16/2024 02:15:36 PM

Document Has Been Signed on 08/16/2024 02:15 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DEVYN LANE FAMILY HOMEFACILITY NUMBER:
197603477
ADMINISTRATOR/
DIRECTOR:		LUIS BRU JR.FACILITY TYPE:
735
ADDRESS:43709 DEVYN LANETELEPHONE:
(661) 816-3411
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Luis Bru Jr.TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Lorena Casillas arrived at 10:00 am and knocked on the door, but there was no answer. LPA called and spoke to Administrator, Luis Bru Jr. LPA was advised that Administrator would arrive shortly. Administrator met with LPA at 10:45 am for an annual required inspection. Entrance interview conducted.

LPA and the Administrator conducted a tour of the facility at 11:20 am. The following was observed:

Facility has four (4) bedrooms and two (2) bathrooms. One (1) bedroom and one (1) bathroom are designated for staff use. Facility has a fire clearance for four (4) ambulatory clients.

Kitchen: LPA conducted a food inspection tour at 11:20 am. LPA observed there to be sufficient stock of two- perishable and seven-day non-perishables foods. Snacks and beverages are available for clients in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

Common Areas: LPA toured all common areas of the facility. LPA observed common areas to be clean and furniture to be in good repair. The facility maintains a comfortable temperature at 72 degrees F. LPA observed fire extinguishers to be full and last serviced on 06/12/2024. Knives and medication are stored in a locked hallway closet inaccessible to clients. 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.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVYN LANE FAMILY HOME
FACILITY NUMBER: 197603477
VISIT DATE: 08/16/2024
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Client rooms: LPA toured the client rooms at 11:30 am. LPA observed rooms to have appropriate bedding sheets, pillowcase, mattress pad, and blankets, which are in good condition. There is at least one chair, nightstand and sufficient lighting for each client. LPA observed extra linens and bedding in a hallway closet.

Bathrooms: LPA observed bathrooms to have appropriate wash your hand signs. LPA observed that clients have sufficient number of supplies for personal hygiene which is provided by the Licensee. The hot water measured at 11:35 am at 105 degrees F.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No pools or bodies were observed on the premises.

Garage: LPA observed there to be an attached garage that is used for general storage and emergency water.

Laundry Room: LPA observed that laundry room is located adjacent to the dining area leading to the garage. Laundry detergents and other cleaning agents and toxins are kept locked in a hallway closet.

Staff Records: At 12:30 pm LPA reviewed staff records.

Client Records: At 1:00 pm LPA reviewed client records.

Interviews: There were no clients present at the time of inspection. All clients are currently at day program.

Medication: At 1:50 pm LPA and Administrator reviewed client medication.

Administrative: Annual fees are current. Administrator emailed LIC500, Bond, and Resident roster to LPA. Administrator has sent in all required documents for Admin Certificate renewal, however they are currently on a pending list. Once Admin Certificate is received Administrator will email it to LPA.

No citations issued. Exit interview conducted. Copy of report emailed to Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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