197609885-12-5-2023-31-AS-ERIS-CY8TSC-20231205135856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609885
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:59:29 PM

Document Has Been Signed on 12/05/2023 01:59 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:	EPHRATAH HOME 1		FACILITY NUMBER:	197609885
ADMINISTRATOR:	AHIABOR, FRANCESS		FACILITY TYPE:	735
ADDRESS:	4605 W. AVENUE J12		TELEPHONE:	(818) 310-7602
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 4		CENSUS: 4	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Alex Ahiabor		TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Evelin Rios made an unannounced ANNUAL/REQUIRED visit to the facility mentioned above. LPA was greeted by staff Alex Ahiabor and LPA explained the purpose of the visit. Upon entry LPA observed the required postings along the facility walls by the front door. Administrator Francess Ahiabor designated staff to sign today's report.

At 11:35 a.m. staff and LPA conducted a physical plant tour and LPA observed the following:

Common Areas: These include the living area and dining area. LPA observed dining and living room furniture in good repair. Dining and living room furniture sits the capacity of the facility. LPA observed two (2) fire extinguishers one (1) is located in the living area and the other was located by the kitchen. LPA observed them fully charged with a serviced date of 08/04/2023.

Kitchen: LPA observed a seven day supply of non-perishable food and a two day supply of perishable foods; properly stored. LPA observed a locked closet by the kitchen. Facility stores the knives, sharps, first aid kit, emergency supply of food and water, PPE, client's medications and facility records in this closet.

Bedrooms: There are four (4) client bedrooms for single use. LPA observed bedrooms to be properly furnished with a bed, linens, night stand, chair, chest of drawers, closet, and adequate lighting.

Bathroom: There are three (3) client bathrooms one (1) is located in a client's bedroom for private use. The bathrooms contained hand soap, paper towels, toilet paper and trash bins. Water temperature was taken in one (1) of the bathroom's sinks and measured over 121.3 degrees F.

Hallway Closets: LPA observed a closet locked that contained an overflow of toiletries such as hand soup, shampoo, paper towels, and cleaning chemicals. (Cont'd on LIC809-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EPHRATAH HOME 1	FACILITY NUMBER: 197609885
	VISIT DATE: 12/05/2023

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(Cont'd from LIC809)

Laundry Room: LPA observed the laundry room on the second floor and contains a washer and dryer. Detergents are locked in the hallway closet.

Garage: The garage is attached to the facility. LPA observed additional storage for the facility.

Backyard: LPA observed a patio area with shade for clients. The side gate leading from the backyard to the front yard was not locked.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by the Alex at 12:00 p.m. and were observed operational.

Client/Staff Records: At approximately 12:13 p.m. four (4) out four (4) client records and (2) staff records were reviewed to insure compliance with licensing forms.

Medications: Refills are either done automatically or clients' must visit with their physician to receive a refill. At approximately 12:40 p.m. LPA and staff reviewed Medication Records for proper documentation. Medication records are maintained manually. Facility maintains Medical Administration Records (MAR).

Staff Interview: At 12:45 p.m. LPA conducted an interview with staff present at the facility.

Deficiency cited (refer to 809-D). Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/05/2023 01:59 PM - It Cannot Be Edited

Created By: Evelin Rios On 12/05/2023 at 01:17 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EPHRATAH HOME 1	FACILITY NUMBER: 197609885
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, random check of one (1) bathroom sink hot water was measured over 121.3°F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Administrator will adjust water temperature and send a picture of the temperature to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Eva Miller

LICENSING EVALUATOR NAME:

Evelin Rios

LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

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