197608040-2-12-2024-31-AS-LCAS-D2E4D5-20240212180010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608040
Report Date: 02/12/2024
Date Signed: 02/12/2024 06:01:13 PM

Document Has Been Signed on 02/12/2024 06:01 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:	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: 4	DATE:	02/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Stephen Racine		TIME COMPLETED:	01:30 PM

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	Licensing Program Analyst (LPA) Lorena Casillas met with back up administrator Stephen Racine for an unannounced one (1) year Required visit for this facility. LPA arrived at 09:30 am and was greeted by Administrator. All four (4) residents were present and in their rooms. LPA informed the Administrator of the purpose of the visit. Infection control: LPA previously reviewed the facility mitigation plan (approved on 04/15/21) to make sure the licensee was following current infection control recommendations. A tour of the physical plant was conducted with the Administrator at 9:50 am. The facility has six (6) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for six (6) ambulatory of which five (5) can be non-ambulatory, and a hospice waiver for four (4). Currently the facility two (2) residents on hospice. Food Inspection: LPA conducted a tour of the kitchen around 10:00 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects being locked and inaccessible to residents in care. The files and medication cabinet was observed to be locked and inaccessible to residents in care in a separate locked room near the entrance. There is a pantry located in the hallway that has a fridge for additional food storage. Continued on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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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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: SARAH'S CARE HOME	FACILITY NUMBER: 197608040
	VISIT DATE: 02/12/2024

NARRATIVE

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Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a night stand, a chair and sufficient lighting for each client.

Bathrooms: LPA observed all bathrooms to have non-skid mats, grab bars, and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 111.8 degrees F.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 71°F. The dual smoke detectors and carbon monoxide detectors were tested and observed to be operational. There are two (2) fire extinguishers, one (1) is in the kitchen and one (1) is in the hallway. The Fire extinguishers were observed to be full and last purchased on 9/15/23. LPA observed the laundry room to not have any chemicals or hazardous items.

Physical environment: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Administrative: Annual fee is current. Administrator Certificate, LIC 500, Liability Insurance, and Client roster were collected.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA conducted a file review of staff records to ensure compliance of licensing forms.

Medications: LPA and Administrator reviewed medication and medication records for proper documentation.

Staff Interviews: At 12:38 pm LPA interviewed staff.

Client Interviews: At 12:52 pm LPA interviewed clients.

An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

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