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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605235
Report Date: 04/27/2026
Date Signed: 04/27/2026 01:11:09 PM

Document Has Been Signed on 04/27/2026 01:11 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:GRANGE GUEST HOME, INC.FACILITY NUMBER:
197605235
ADMINISTRATOR/
DIRECTOR:		JOEL FLETCHERFACILITY TYPE:
735
ADDRESS:43518 GRANGE STREETTELEPHONE:
(661) 948-9258
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
04/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Belinda Rene HicksTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 04/27/2026 at 10:00 am Licensing Program Analyst (LPA) Lorena Casillas met with administrator Belinda Rene Hicks for an unannounced one (1) year required visit for this facility. Upon arrival LPA was greeted and granted access by the Administrator. LPA explained the reason for the visit and an entrance interview was conducted.

Infection Control and Emergency Preparedness Plan: LPA reviewed facility Infection Control Plan and Emergency Preparedness Plan to make sure protocols are being reviewed and/or updated annually. Plans were discussed and updated. Emergency drills are up to date and last held on 04/01/2026.

A tour of the physical plant was conducted with the Administrator at 11:20 am. The facility has five (5) bedrooms and two (2) bathrooms. Three (3) rooms are used for clients, one (1) room is used for storage and one (1) room is a staff bedroom. Facility is fire cleared for two (2) ambulatory clients and two (2) non ambulatory for a total of four (4) clients. The following was observed:



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 71˚ F. LPA observed fire extinguisher to be full and last purchased on 03/31/2026. At 11:20 am the carbon monoxide and interconnected smoke detectors were tested and functioning properly.

Laundry service: The laundry room remains locked at all times and was observed to be neat and clean. Detergents and chemicals were observed to be in a locked cabinet within the laundry room.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2026
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: GRANGE GUEST HOME, INC.
FACILITY NUMBER: 197605235
VISIT DATE: 04/27/2026
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Kitchen: LPA toured the kitchen at 11:30 am. LPA observed there to be sufficient stock of two-day perishable and seven-day non-perishables foods. The menu was posted for review. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed the knives and chemicals locked under the sink and observed the medication cabinet locked and inaccessible to clients in care.

Client Bedrooms: LPA toured the client rooms and observed rooms to have appropriate bedding, a chair, a nightstand and sufficient lighting for each client.

Bathrooms: At 11:45 am LPA observed all bathrooms to have appropriate grab bars and wash your hand signs. Hot water was measured within regulation at 108.2˚F.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with an umbrella for shade. LPA observed no bodies of water on the premises. Area was clear of obstructions.



Garage: LPA observed an attached garage that is locked and inaccessible to clients. The garage is used for extra storage. LPA observed an extra refrigerator and deep freezer located in the garage for overflow of foods.

Client/Staff Interviews: All clients were out in the community at day program, no clients were interviewed. One (1) staff present was interviewed.

Client/Staff Files: At approximately 12:00 pm LPA conducted a file review of staff and client records, no discrepancies were found.

Administrative: LIC500, Bond, Administrator Certificate and client roster are up to date. Annual fees are current.

No citations issued. Exit interview conducted. Copy of report provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC809 (FAS) - (06/04)
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