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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609822
Report Date: 11/16/2024
Date Signed: 11/16/2024 02:38:30 PM

Document Has Been Signed on 11/16/2024 02:38 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/
DIRECTOR:		CARR, KELSIEFACILITY TYPE:
735
ADDRESS:27901 PINEBANK DRTELEPHONE:
(661) 296-8977
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY: 4CENSUS: 2DATE:
11/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator Kelsie Carr for a One (1) Year Required visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 11:00 AM and the following was noted:

There is one entrance being utilized at the facility. The facility has five (05) bedrooms total of which three (03) are used for residents and two (02) bathrooms of which one (01) is utilized by residents. The facility is fire cleared for four (04) ambulatory residents. The facility is currently occupying two (02) ambulatory residents. The backyard has outdoor furniture, with a covered shaded area for clients and visitors. 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.

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 73°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 11/06/2024.

(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARR FAMILY HOME
FACILITY NUMBER: 197609822
VISIT DATE: 11/16/2024
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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 114.9°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.

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: 11/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2024
LIC809 (FAS) - (06/04)
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