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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609885
Report Date: 01/25/2022
Date Signed: 01/25/2022 12:10:58 PM

Document Has Been Signed on 01/25/2022 12:10 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:EPHRATAH HOME 1FACILITY NUMBER:
197609885
ADMINISTRATOR:AHIABOR, FRANCESSFACILITY TYPE:
735
ADDRESS:4605 W. AVENUE J12TELEPHONE:
(818) 310-7602
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 2DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Francess Ahiabor TIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Shira Stamps, met with Administrator Francess Ahiabor for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:18 am, there was no answer at the door. LPA called Administrator at 10:21am, and the Administrator stated she was on her way. The Administrator arrived at 10:55 am. LPA informed the Administrator of the purpose of the visit. The residents were observed to be in their rooms watching TV and/or resting.

Infection control: LPA reviewed facility mitigation plan (approved on 02/06/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the Administrator and asked to answer all infection control questions. LPA was also asked to sign-in.

A physical plant tour was conducted with Administrator at 11:00 am. The facility has four (4) bedrooms and three (3) bathrooms currently occupying two (2) residents. The facility is Fire Cleared for four (4) ambulatory.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident.

Laundry
At 11:13am, LPA observed the Laundry room to be located upstairs. All chemicals/hazardous materials were in a locked closet, and inaccessible to residents in care.

Continued...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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: EPHRATAH HOME 1
FACILITY NUMBER: 197609885
VISIT DATE: 01/25/2022
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Bathrooms
At 11:15 am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 11:20 am and measured within regulation at 115.1 degrees F.

Food Inspection


LPA conducted a tour of the kitchen at 11:00 am and observed there to be sufficient stock of two day perishables and seven day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. Medications and resident/staff files were observed to be locked in a closet near the kitchen.

Physical environment
LPA toured the outside area of the facility at 11:10 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Living and dining
At 11:12 am, LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature downstairs at 69°F, and upstairs at 71°F. The smoke detectors and carbon monoxide detector were tested and observed to be operational at 11:25 am. There is one (1) fire extinguisher located in the kitchen, and one (1) fire extinguisher located in the living room. The Fire extinguishers were observed to be full and last serviced on 11/02/21.

Garage
At 11:10 am, LPA observed the garage to be attached to the facility and currently being used storage, and parking for staff.

Administrative: LPA collected the resident roster and LIC.500.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
LIC809 (FAS) - (06/04)
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