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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608040
Report Date: 12/02/2024
Date Signed: 12/02/2024 02:14:14 PM

Document Has Been Signed on 12/02/2024 02:14 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 HOMEFACILITY NUMBER:
197608040
ADMINISTRATOR/
DIRECTOR:		SARAH SHIRLEYFACILITY TYPE:
740
ADDRESS:43861 RYCKEBOSCH LANETELEPHONE:
(661) 946-0198
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 4DATE:
12/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Stephen RacineTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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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 three (3) 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 care clean and inaccessible to pests. LPA observed all knives and sharp objects being locked and inaccessible to residents in care. The files and medication were observed to be locked in a cabinet and inaccessible to residents in care in a separate room near the entrance. There is a pantry located in the hallway that has a fridge for additional food storage.

Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, a chair and sufficient lighting for each client. LPA observed the staff room to have a locked. There is an office with an additional freezer.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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: 12/02/2024
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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 105 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 70°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 9/18/24.

Laundry: LPA observed the laundry room to not have any chemicals or hazardous items. Detergent is kept in the locked office.

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.

Garage: LPA observed a locked attached garage used for extra storage.

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 01:00 pm LPA interviewed staff.

Client Interviews: At 01:30 pm LPA interviewed clients.

An exit interview was conducted, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
LIC809 (FAS) - (06/04)
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