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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609822
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:41:25 PM

Document Has Been Signed on 10/21/2021 12:41 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 FAMILY HOMEFACILITY NUMBER:
197609822
ADMINISTRATOR:CARR, KELSIEFACILITY TYPE:
735
ADDRESS:27901 PINEBANK DRTELEPHONE:
(661) 296-8977
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY: 4CENSUS: 3DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kelsie Carr, AdministratorTIME COMPLETED:
12:28 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator Kelsie Carr for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 9:50 AM and the following was noted:
There is one entrance being utilized at the facility, there are required poster 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 mask upon entrance and during the visit. The facility has submitted an approved Mitigation plan. Signs to wear a mask and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a storage cabinet near the front door and in the garage. The facility has five (05) bedrooms total of which three (03) are used for residents and two (02) bathroom of which one (01) is utilized by residents. The facility is fire cleared for zero (00) non-ambulatory, four (04) ambulatory and zero (00) bedridden residents. The facility is currently occupying three (03) ambulatory residents. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The facility has a swimming pool located in the backyard which is gated and locked. The garage is currently being used as laundry/storage room. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the kitchen. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.
(continued on LIC 809-C)


SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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 FAMILY HOME
FACILITY NUMBER: 197609822
VISIT DATE: 10/21/2021
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 Knives and sharps are observed to be locked in a kitchen cabinet inaccessible to residents. Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is also a carbon monoxide detector installed at the facility. Fire extinguishers are located in the kitchen and observed to be full and last inspected on 03/17/2021. Staff Rooms: Staff rooms were observed to be locked and located on the far end of the hallway. No medications are observed in the staff room. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit. Clients have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 109.4°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinet. Medications: LPA observed medication cabinet to be locked and inaccessible to residents, located in the kitchen. There is a complete first aid kit located inside the cabinet near the foyer.

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

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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