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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609885
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:45:43 PM

Document Has Been Signed on 01/15/2025 12:45 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 1FACILITY NUMBER:
197609885
ADMINISTRATOR/
DIRECTOR:		AHIABOR, FRANCESSFACILITY TYPE:
735
ADDRESS:4605 W. AVENUE J12TELEPHONE:
(818) 310-7602
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Leslie Clarkson (Backup Administrator)TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 1/15/2025 at 9:25 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conduct an unannounced annual inspection. LPA met with Leslie Clarkson who granted access. Leslie is the administrator designee, LPA Rios explained the reason for the visit. Administrator will not be able to meet with LPA at the facility, Leslie is designated to sign today report. This is an Adult Residential Facility (ARF) Level 2 with an approved fire clearance for 4 ambulatory clients.

At approximately 9:40 a.m., LPA along with the administrator designee conducted a physical plant tour of the facility inside and out and the following was observed.

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 fully charged and two carbon monoxide detectors that were tested and observed operational.

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) bathroom downstairs and measured at 119.4 degrees F. within regulation. LPA observed night lights leading to the bathrooms.

Laundry Room: LPA observed the laundry room on the second floor accessible to clients. The laundry room contains a washer and dryer that were observed functional. (Continue on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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: 01/15/2025
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(Continued from LIC809) LPA observed a closet near the laundry room locked that contained an overflow of toiletries, detergent, paper towels, and cleaning chemicals.

The smoke detectors that are hardwired and interconnected were tested by staff at 9:50 a.m., and were observed operational.

Kitchen: LPA observed a freezer, a refrigerator, stove, microwave and dishwasher. LPA observed a seven day supply of non-perishable food and a two day supply of perishable foods. LPA observed a locked closet by the kitchen. Facility stores the knives, sharps, first aid kit, emergency supply of food and water, client's medications and facility records are kept locked in a closet by the kitchen.

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

Backyard: LPA observed a patio area with shade for clients. No bodies of water observed.

Client, Staff and Facility Records: At approximately 10:20 a.m. LPA reviewed facility records, such as the Emergency Disaster Plan (LIC610D), Personnel Record (LIC500), staff schedule 2024-2025, Surety Bond, emergency drills and Infection Control Plan. At 11:15 a.m. LPA reviewed four (4) out four (4) client records to ensure compliance with licensing forms. At 11:58 a.m. LPA reviewed four (4) staff records to ensure compliance with licensing forms and to confirm training was up to date.



Medications: Two pharmacies are used to fill medication and clients' with the assistance of staff pick up medication in person. . LPA reviewed Medication Records for proper documentation. Medication records are maintained manually. Facility maintains Medical Administration Records (MAR).

No deficiencies cited on todays visit. Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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