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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604095
Report Date: 10/12/2022
Date Signed: 10/12/2022 02:57:59 PM

Document Has Been Signed on 10/12/2022 02:57 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:RYCKEBOSCH FAMILY HOMEFACILITY NUMBER:
197604095
ADMINISTRATOR:LUIS BRU JR.FACILITY TYPE:
735
ADDRESS:43639 RYCKEBOSCH LANETELEPHONE:
(661) 816-3411
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Luis Bru Jr., LicenseeTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Shira Stamps arrived at the facility for an unannounced one (1) year Required visit for this facility.

LPA arrived at 1:45 pm and was greeted by caregiver Gladys Gomez. Two (2) clients were observed in the dining room doing activities, and the rest of the clients were observed to be in their rooms resting or watching TV. LPA spoke to Licensee over phone, who stated he was at a doctor appointment and would be able to arrive in 45 minutes. LPA informed the Licensee of the purpose of the visit and informed him the inspection would begin with the caregiver. The Licensee stated the caregiver could sign the report if he did not make it to the facility before the inspection was completed.

A tour of the physical plant was conducted with caregiver Gladys at 2:10 pm. The facility has four (4) bedrooms and two and a half (2 1/2) bathrooms currently occupying four (4) clients. One (1) bathroom and bathroom is designated for staff use only. The facility is Fire Cleared for four (4) ambulatory.

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

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

Bathrooms
At 2:25pm LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 105.0 degrees F. CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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: RYCKEBOSCH FAMILY HOME
FACILITY NUMBER: 197604095
VISIT DATE: 10/12/2022
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Laundry/Garage
LPA observed no chemicals/hazardous items located in the Laundry/Garage. The garage is being used for PPE supplies and extra storage

Food Inspection
LPA conducted tour at the kitchen around 2:17 pm 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.

Physical environment
LPA toured the outside area of the facility at 2:30 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 comfortable temperature at 78°F. The smoke detectors and carbon monoxide detector were tested and observed to be operational at 2:30 pm. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 06/17/22. LPA observed all knives and sharp object, Medications, 1st aid kit, client and staff files located in a locked closet inaccessible to clients in care.

Administrative: LPA reviewed the staffing schedule and client roster. Annual fee is not current, due 10/23/22. LPA reviewed the infection control plan received on 9/21/22.

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

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

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
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