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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608146
Report Date: 05/03/2022
Date Signed: 05/03/2022 04:50:26 PM

Document Has Been Signed on 05/03/2022 04:50 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:CARR ADULT FAMILY HOMEFACILITY NUMBER:
197608146
ADMINISTRATOR:KIMBERLY CARRFACILITY TYPE:
735
ADDRESS:27810 DANDELION DRIVETELEPHONE:
(661) 263-1577
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY: 4CENSUS: DATE:
05/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Kimberly CarrTIME COMPLETED:
04:36 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Kimberly Carr for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:45pm and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs are posted outside. Hand washing, coughing etiquette, physical distancing and other necessary signs are posted in the bathroom and throughout the facility. The facility has enough PPE supplies. The facility has a total of five (05) bedrooms and three (03) bathrooms. The facility is fire cleared for four (04) ambulatory clients. The facility is currently occupying two (02) ambulatory clients. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a swimming pool/body of water with the required fencing and locking mechanism. The garage is currently being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to clients. The living and dining rooms are neat and clean with appropriate furniture. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located near the front entrance, observed to be full and last inspected on 10/22/2021.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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: CARR ADULT FAMILY HOME
FACILITY NUMBER: 197608146
VISIT DATE: 05/03/2022
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No medications observed in the staff room. The clients' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Clients have enough personal hygiene products provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 115.3°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents.


Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
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