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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604095
Report Date: 10/15/2025
Date Signed: 10/15/2025 02:36:50 PM

Document Has Been Signed on 10/15/2025 02:36 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:RYCKEBOSCH FAMILY HOMEFACILITY NUMBER:
197604095
ADMINISTRATOR/
DIRECTOR:		LUIS BRU JR.FACILITY TYPE:
735
ADDRESS:43639 RYCKEBOSCH LANETELEPHONE:
(661) 816-3411
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
10/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Luis Bru Jr.TIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 10/15/2025 at 09:30 a.m. Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility listed above to conduct an unannounced required annual inspection. LPA was greeted by Administrator Luis Bru, LPA explained the reason for the visit. Entrance interview conducted.

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 ½) bathrooms. All clients were currently out in the community.

A tour of the physical plant was conducted with administrator at approximately 10:00 a.m. and the following was observed:

Kitchen: LPA conducted a tour of the kitchen at approximately 10:15 a.m. and observed there to be sufficient supply of two-day perishable and seven-day non-perishable 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 06/02/2025.

Living and Dining: LPA observed the living and dining areas to be clean and clear of clutter. The furniture was in good repair and sits the capacity of the facility. Temperature was at a comfortable 72˚F.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: RYCKEBOSCH FAMILY HOME
FACILITY NUMBER: 197604095
VISIT DATE: 10/15/2025
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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 nightstand, chair, bedding and with sufficient lighting and storage.

LPA observed Administrator test a smoke detector at approximately 10:45 a.m. detector is interconnected to other detectors located throughout the facility. Carbon monoxide detector was observed to be functioning properly.



Bathrooms: The facility has 2 ½ bathrooms. One (1) is located in a staff bedroom. LPA took water temperature and temperature was 109.2˚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 area in the garage accessible to clients and staff. LPA observed a second refrigerator used to store an overflow of groceries.

Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for client use. No bodies of water on the property.

Client/Staff Records: At approximately 11:30 a.m. four (4) out four (4) client records and three (3) staff records were reviewed to ensure compliance with licensing forms. Records are kept locked in a hallway closet.

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).

Staff/Client Interviews: There were no clients or staff present, interviews were not conducted.

Administrative: Fees are current. Copies of LIC500, Client roster, and Bond will be emailed to LPA.

No citations issued. Exit Interview Conducted. A Copy of the Report Issued.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
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