197608040-12-20-2021-31-AS-NGID-CBS32T-20220218165224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608040
Report Date: 12/20/2021
Date Signed: 12/20/2021 01:20:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2021 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20211214112707

FACILITY NAME:	SARAH'S CARE HOME		FACILITY NUMBER:	197608040
ADMINISTRATOR:	SARAH SHIRLEY		FACILITY TYPE:	740
ADDRESS:	43861 RYCKEBOSCH LANE		TELEPHONE:	(661) 946-0198
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	6	CENSUS: 5	DATE:	12/20/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sarah Shirely		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff was not wearing a mask.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 10:00am Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above for an initial complaint visit. LPA was greeted at the door by caregiver, Steve Racine and Administrator Sarah Shirley. Entrance interview conducted.
At approximately 10:09 am, LPA conducted a physical plant walk through, and LPA did not observe any immediate health and safety issues during this visit.
Allegation: Facility staff was not wearing a mask.
Upon arrival, LPA observed two (2) out of two (2) staff members not wearing masks. Based upon COVID-19 guidelines, mask are required for all facility workers. The Facility is not following the mitigation plan (approved 4/15/21). LPA discussed the importance of wearing mask while taking care of the residents in care.
Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations are being cited on the attached LIC 9099D.
Exit interview. Appeal Rights discussed. Citation issued and copy of report delivered to Administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 31-AS-20211214112707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SARAH'S CARE HOME	FACILITY NUMBER: 197608040
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/27/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468(a)(2) Personal Rights. (a) Each resident shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agrees to keep masks by the entrance, and will post signs to remind facility staff to wear masks at all times. Administrator will submit a picture of the signs posted in the facility to the LPA.
	8 9 10 11 12 13 14	Bases on observations, On 12/20/21, licensee did not ensure the personal rights of persons in care to a safe, healthy, and comfortable home and engaged in conduct inimical to the health, welfare, and safety of persons in care, in that facility staff did not wear face coverings while in the facility,	8 9 10 11 12 13 14	as required by CA Dept. of Public Health Guideline on the Use of Face Coverings issued June 18,2020 and updated November 16,2020, and an individual mask exception did not apply.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2021 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20211214112707

FACILITY NAME:	SARAH'S CARE HOME		FACILITY NUMBER:	197608040
ADMINISTRATOR:	SARAH SHIRLEY		FACILITY TYPE:	740
ADDRESS:	43861 RYCKEBOSCH LANE		TELEPHONE:	(661) 946-0198
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	6	CENSUS: 5	DATE:	12/20/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sarah Shirely		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not following COVID-19 guidelines.
Residents were not provided paper product or towels in the restroom.
Facility is odoriferous.
Facility trash can was overflowing with bed pads.
Facility is not maintained clean.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20211214112707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SARAH'S CARE HOME	FACILITY NUMBER: 197608040
	VISIT DATE: 12/20/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on observations, the allegation, “Facility is not following COVID-19 guidelines, is deemed unsubstantiated.

Allegation: Residents were not provided paper product or towels in the restroom.

During the physical plant tour, LPA observed paper products, such as toilet paper and paper towels, located in all resident restrooms. Therefore, based on observation the allegation, “Residents were not provided paper product or towels in the restroom,” is deemed unsubstantiated.

Allegation: Facility is odoriferous.

During the physical plant tour, LPA did not observe an odoriferous smell. Therefore, based on observations the allegation, “Facility is odoriferous,” is deemed unsubstantiated.

Allegation: Facility trash can was overflowing with bed pads.

During the physical plant tour, LPA observed all trash cans to be empty. Therefore, based on observations the allegation, “Facility trash can was overflowing with bed pads,” is deemed unsubstantiated.

Allegation: Facility is not maintained clean.

During the physical plant tour, LPA observed the facility to be clean and in good repair. At 11:22am, LPA observed facility staff cleaning the kitchen after breakfast was done. Therefore, based on observations the allegation, “Facility is not maintained clean,” is deemed unsubstantiated.

Exit interview conducted. Report delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4