197608043-9-16-2022-31-AS-SSTS-CJBRTH-20220916131823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608043
Report Date: 09/16/2022
Date Signed: 09/16/2022 01:18:34 PM

Document Has Been Signed on 09/16/2022 01:18 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:	BOOTS BETTER LIVING		FACILITY NUMBER:	197608043
ADMINISTRATOR:	WILLIE JORDAN		FACILITY TYPE:	735
ADDRESS:	3021 KILDARE STREET		TELEPHONE:	(661) 951-9548
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 6	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Willie Jordan, Administrator		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) Shira Stamps met with Administrator Willie Jordan for an unannounced one (1) year Required visit for this facility. LPA arrived at 11:15am and was greeted by a caregiver. The caregiver was not wearing a mask. One (1) client was observed in the kitchen. The rest of the clients were attending their day programs. The Administrator arrived about 11:35am. LPA informed the Administrator of the purpose of the visit. Infection control: LPA reviewed the facility mitigation plan (approved on 02/22/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA signed-in and sanitizer was available. A tour of the physical plant was conducted with Administrator at 11:40am. The facility has four (4) bedrooms and three (3) bathrooms currently occupying six (6) clients. One (1) bedroom is designated for a game room. The facility is Fire Cleared for six (6) ambulatory. Food Inspection LPA conducted tour at the kitchen around 11:40am observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all medications, client files, and knives and sharp object being locked and inaccessible to clients in care. Garage LPA observed the garage to be attached to the facility and currently being used for storage and an extra refrigerator. CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: BOOTS BETTER LIVING	FACILITY NUMBER: 197608043
	VISIT DATE: 09/16/2022

NARRATIVE

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Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 78°F. The dual smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:50am. There is one (1) fire extinguishers located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 05/16/22.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client. LPA observed PPE supplies and chemicals/hazardous items in the locked closet located in the game room.

Bathrooms
At 11:47am LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 114.5 degrees F.

Laundry
LPA observed chemicals/hazardous items in the locked laundry room.

Physical environment
LPA toured the outside area of the facility at 11:50am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Administrative: LPA requested copies of the LIC 500, the client roster, and staff COVID training files. Annual fee is current. LPA reminded the Administrator to keep all files maintained.

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

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2022 01:18 PM - It Cannot Be Edited

Created By: Shira Stamps On 09/16/2022 at 12:51 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BOOTS BETTER LIVING	FACILITY NUMBER: 197608043
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85095.5(a)(5)

85095.5 (a)(5) Infection Control Requirements. All staff and volunteers, regardless of having direct contact with clients, shall practice and maintain respiratory etiquette as specified below to minimize exposure to potential illness. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that staff were not wearing masks as per CDC and CDPH guidance, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2022
	Plan of Correction
1 2 3 4	The Adminitraror will inform in writting how the facility will abide by all Center for Disease Control and Department of Public Health Inectious control guidance.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Gillyard

LICENSING EVALUATOR NAME:

Shira Stamps

LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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