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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197608040
Report Date:
11/04/2022
Date Signed:
11/04/2022 12:13:13 PM
Document Has Been Signed on
11/04/2022 12:13 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
CCLD Regional Office
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
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:
11/04/2022
TYPE OF VISIT:
Case Management - Health Checks
UNANNOUNCED
TIME BEGAN:
11:43 AM
MET WITH:
Steven Racine - Administrator
TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility to check on Resident #1 (R1 to ensure that R1 is safe and well.
LPA conducted physical plant tour at 11:47 AM and conducted interviewed with R1 and administrator between 10:50 to 12:00 PM.
LPA interview with R1 revealed that R1 is doing fine at the facility at this time.
There is no health and safety concern observed during this visit.
Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME:
Naira Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Jose Gary Tan
TELEPHONE:
(323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE:
11/04/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/04/2022
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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