<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608040
Report Date: 02/03/2022
Date Signed: 02/03/2022 03:48:19 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 HOMEFACILITY NUMBER:
197608040
ADMINISTRATOR:SARAH SHIRLEYFACILITY TYPE:
740
ADDRESS:43861 RYCKEBOSCH LANETELEPHONE:
(661) 946-0198
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:6CENSUS: 5DATE:
02/03/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Steve Racine, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not following COVID-19 guidelines.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 1:30 pm, Licensing Program Analyst (LPA) Shira Stamps conducted a subsequent complaint visit regarding the complaint allegation listed above. LPA met with the facility Administrator Steve Racine. Entrance interview conducted, and physical plant tour conducted.

Allegation: Facility is not following COVID-19 guidelines.

This report is being issued based on further review of the information gathered to change the findings of the report dated on 12-20-21. The department conducted an initial complaint visit with the Administrator. During the initial visit, LPA conducted a physical plant tour and interviewed staff and the Administrator. Based on interviews and observations the allegation, “Facility staff was not wearing a mask,” was deemed substantiated. Wearing a mask for all facility staff is part of the COVID-19 guidelines, therefore based on further review of the information gathered, the allegation, “Facility is not following COVID-19 guidelines,” is deemed substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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 3
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: 02/03/2022
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
Exit interview conducted. Citation issued and copy of report delivered to Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2022
Section Cited
CCR
87468(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 Licensee agrees to conduct a training for all staff to review the mitigation plan approved on 4/15/21, and will submit to the LPA signatures of all staff that have completed the training.
8
9
10
11
12
13
14
Bases on observations, the 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 follow COVID-19 guidelines.
8
9
10
11
12
13
14
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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3