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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608040
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:01:25 AM


Document Has Been Signed on 12/15/2022 11:01 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: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: 3DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Steve Racine - AdministratorTIME COMPLETED:
11:10 AM
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On 12/15/22 Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator/Licensee Steve Racine. LPA observed covid-19 signage, hand sanitizer, PPE supplies and a visitor sign in log. LPA was asked by staff to sign and LPAs temperature was taken. The purpose of the visit was explained, and an entrance interview was conducted.

LPA initiated a physical plant tour, Facility is a Residential Care Facility for the Elderly which was licensed for 6 residents, five (5) non-ambulatory, of which one (1) may be bedridden. Facility has been approved for a hospice waiver for four (4). LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguishers was observed in the hallway and kitchen, both have a date of purchase of 9/16/2022. Smoke detectors and carbon monoxide monitors are dual linked and were observed to be functional. Facility maintains a temperature of 69 degrees Fahrenheit. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and medication closet. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There are various clean covered shaded areas in the back yard and there are no bodies of water.

No deficiencies issued during today’s visit. Report was signed and delivered and an exit interview was conducted.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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