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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608471
Report Date: 05/13/2024
Date Signed: 05/13/2024 02:29:50 PM

Document Has Been Signed on 05/13/2024 02:29 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BOOTS BETTER LIVING IIFACILITY NUMBER:
197608471
ADMINISTRATOR/
DIRECTOR:		STACI JORDANFACILITY TYPE:
735
ADDRESS:42444 BUTTERSCOTCH LANETELEPHONE:
(323) 394-9906
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 4DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Will JordanTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 05/13/2024 at 9:55 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection using the CARE Inspection Tool. This is an Adult Residential Facility (ARF), level 3 with an approved fire clearance for six (6) ambulatory clients. LPA knocked on the door and nobody answered. LPA contacted Administrator Will Jordan who informed LPA they will be able to meet LPA at the facility. LPA met with administrator at approximately 10:20 a.m. and LPA explained the reason for the visit.

At approximately 10:25 a.m. LPA and the administrator toured the physical plant of the facility, and the following was observed.

Common areas: These include the game room and the living room. Both rooms were observed clean and properly furnished. LPA observed a television in each room, games and activities for clients to use. LPA observed a first aid kit and manual accessible.
Kitchen/ Dining areas: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable supply of food; properly stored. Administrator stated they do the grocery shopping every Monday or as needed. LPA observed one (1) fire extinguisher fully charged with purchase receipt attached. Dining areas had appropriate table and chairs to sit the capacity of the facility. Clients' medications and facility files are kept locked in a cabinet by the kitchen.
Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for client use.
Laundry/Garage: Laundry room is located on the ground level and accessible to clients. Detergents, extra cleaning supplies, were observed locked in a closet in the laundry room.
(Continued on to LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BOOTS BETTER LIVING II
FACILITY NUMBER: 197608471
VISIT DATE: 05/13/2024
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(Continued LIC809-C)

Washer and dryer were observed operational. The Garage is located through the laundry room. LPA observed the facility vehicle parked in the garage and extra PPE.
Bathrooms: The facility has three (3) total bathrooms one (1) of which is in the staff bedroom for staff use. At approximately 11:07 a.m. LPA took hot water temperature from the second floor client bathroom and the hot water temperature read 118.8 degrees Fahrenheit, within regulation. LPA observed both bathrooms to be clean and properly supplied with toilet paper, hand soap, paper towels and trash bins with lids.
Bedrooms: There are a total of four (4) bedrooms, one (1) of which is designated for staff use. LPA inspected three (3) out of three (3) client bedrooms. Bedrooms can be shared. LPA observed each client room to be properly furnished with two beds, appropriate night stand, bedding and with sufficient lighting and storage. LPA observed extra linens in the hallway outside the bedrooms.

At 11:01 a.m. LPA observed the administrator test a smoke/carbon monoxide detector that is hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly.

Facility Records: Records reviewed include facility, staff and clients records. At approximately 11:21 a.m. four (4) out four (4) client records and (3) staff records were reviewed to insure compliance. LPA and administrator discussed facility's infection control plan, admission agreements and clients' Individual Program Plans (IPP).
Medications: Centrally stored medications were observed locked in a cabinet by the kitchen. At approximately 1:15 p.m. medications and medication records were reviewed for proper documentation. Centrally Stored Medication Records are filled by the facility and the facility keeps Medication Administration Records (MARs).


Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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