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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604095
Report Date: 12/22/2023
Date Signed: 12/22/2023 03:42:20 PM

Document Has Been Signed on 12/22/2023 03:42 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
N LA & CEN COA AC/SC, 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: 3DATE:
12/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Luis Bru JR.TIME COMPLETED:
04:00 PM
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On 12/22/2023 at 1:20 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced required annual inspection. LPA rang the door bell and nobody answered. LPA telephoned administrator. Administrator stated they will meet LPA at the facility. Administrator arrived to the facility and LPA explained the reason for the visit.

The facility is Fire Cleared for four (4) ambulatory clients for a total capacity of four (4) clients. The facility has four (4) bedrooms and two and a half (2 1/2) bathrooms.

A tour of the physical plant was conducted with administrator at approximately 2:00 p.m. and the following was observed:

Food Inspection: LPA conducted a tour of the kitchen at approximately 2:00 p.m. and observed there to be sufficient supply of two-day perishables and seven-day non-perishables foods, properly stored. Food storage and preparation areas are clean and clear of clutter. LPA observed all knives, sharp objects, the first aid kit with manual up to date and detergents locked in a closet by entrance and inaccessible to clients in care. LPA observed one (1) fire extinguisher to be fully charged last serviced 06/09/2023.

Living and dining areas: LPA observed the living areas and dining area to be clean and clear of clutter. The furniture was in good repair and sits the capacity of the facility.

Bedrooms: LPA inspected four (4) bedrooms, three (3) of which are for client use. One (1) bedroom is shared. LPA observed each client room to be properly furnished beds, appropriate night stand, chair, bedding and with sufficient lighting and storage.

(Continued on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2023
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RYCKEBOSCH FAMILY HOME
FACILITY NUMBER: 197604095
VISIT DATE: 12/22/2023
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(Continued from LIC809)
LPA observed a administrator test a smoke detector at approximately 02:12 p.m. Detector is interconnected to other detectors located through out the facility. Carbon monoxide detector was observed to be functioning properly.

Bathrooms: The facility has 2 1/2 bathrooms. One (1) is located in the a staff only bedroom. LPA took water temperature from one (1) out 2 1/2 bathrooms and temperature was between 105 and 120 degrees F. LPA observed the bathrooms to be clean and properly supplied with hand soap, toilet paper, paper towels and trash bins.

Garage: The garage is attached. LPA observed the laundry is located in the garage accessible to clients and staff. LPA observed a second refrigerator used to store an over flow of groceries.

Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for client use.

Client/Staff Records: At approximately 2:35 p.m. three (3) out three (3) client records and three (3) staff records were reviewed to insure compliance with licensing forms. Records are kept locked.

Medications: Centrally stored medications are maintained locked in a kitchen cabinet. Medications were observed locked. Centrally Stored Medication Records were reviewed for proper documentation. Medication records are maintained manually. Facility also keeps Medication Administration Records (MAR).


Pursuant to Title 22 Division of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC809 (FAS) - (06/04)
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