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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608146
Report Date: 06/12/2023
Date Signed: 06/12/2023 04:45:56 PM

Document Has Been Signed on 06/12/2023 04:45 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: 2DATE:
06/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Kimberly CarrTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with the administrator, Kimberly Carr, for a One (1) Year Required visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 11:30 AM and the following was noted:

There is one entrance being utilized at the facility. The facility has a designated outdoor visitors' area located in the front of the building. 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 73°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 10/18/2022.
(CONT. LIC 9099-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2023
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: 06/12/2023
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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 114°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.

In addition to the physical plant inspection, residents and staff records were reviewed.

LPA reviewed files of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Residents’ files appear to be complete and updated. Staff present files were also reviewed, staff files appear to be complete and updated.

No health and safety hazards noted during the visit.

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

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC809 (FAS) - (06/04)
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