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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605235
Report Date: 03/10/2022
Date Signed: 03/10/2022 11:16:18 AM

Document Has Been Signed on 03/10/2022 11:16 AM - 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:GRANGE GUEST HOME, INC.FACILITY NUMBER:
197605235
ADMINISTRATOR:JOEL FLETCHERFACILITY TYPE:
735
ADDRESS:43518 GRANGE STREETTELEPHONE:
(661) 948-9258
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Belinda Hicks, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Belinda Hicks for an unannounced one (1) year Required visit for this facility. LPA arrived at 9:58 am and was greeted by caregiver, Lesia James. The Administrator arrived at 10:10am, and LPA informed the Administrator of the purpose of the visit. The Administrator was not able to stay the entire visit, and designated caregiver Lesia James to sign the report.

Infection control: LPA reviewed the facility mitigation plan (approved on 03/13/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened and sanitizer was available upon entry.

A tour of the physical plant was conducted with the Designee at 10:13 am. The facility has five (5) bedrooms and two (2) bathrooms currently occupying three (3) clients. Two (2) bedrooms are currently being used for staff use only.

Food Inspection
LPA conducted a tour of the kitchen around 10:13 am and 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. LPA observed all knives and sharp objects locked in the cabinet under the sink with chemicals and cleaning supplies. LPA observed all medications in a locked cabinet inaccessible to clients in care.

Living and dining
At 10:15 am, LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 66°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:25 am. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 04/15/21. LPA observed staff and resident’s files locked in the hallway closet.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRANGE GUEST HOME, INC.
FACILITY NUMBER: 197605235
VISIT DATE: 03/10/2022
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Resident Rooms
At 10:20 am, LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client. LPA observed extra bedding and sheets located in the hallway cabinets.

Bathrooms
At 10:20 am LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted in the bathroom. Hot water was tested and measured within regulation at 119.8 degrees F

Laundry/Garage
At 10:22 am, LPA observed the laundry room located in the garage. The Garage is attached to the facility and currently being used for extra storage, PPE supplies, and an extra refrigerator.

Physical environment
LPA toured the outside area of the facility at 11:07 am. LPA observed appropriate outdoor furniture. No bodies of water on the premises.

Administrative: LPA collected the LIC.500. Annual fee is current.

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

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

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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