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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609885
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:20:39 PM


Document Has Been Signed on 12/20/2022 03:20 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:AHIABOR, FRANCESSFACILITY TYPE:
735
ADDRESS:4605 W. AVENUE J12TELEPHONE:
(818) 310-7602
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:4CENSUS: 4DATE:
12/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Leslie ClarksonTIME COMPLETED:
03:35 PM
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On 12/20/2022 at 2:10 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA was greeted by Leslie Clarkson who was wearing a mask and granted access. LPA explained the reason for the visit. According to Leslie he is a back-up Administrator and is authorized to sign this report. LPA reviewed the Mitigation Plan approved 02/06/2021. The inspection tool was used to complete the visit.

At 2:11 p.m. LPA began a physical plant tour of the facility and the following was observed:

Infection control: Leslie took LPAs temperature and asked LPA to sign in. LPA observed appropriate infection control signs posted at entry and in the hallway by the bedrooms. LPA observed hand washing signs in the bathrooms and trash bins with lids. Leslie states the facility has enough PPE for 30 days.

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Knives are kept locked in a closet by the kitchen inaccessible to clients. LPA observed a 2-day perishable and a 7-day non-perishable supply of food.

Dining / Living Areas: The dining and living areas were well lit, clean and clear of clutter. Furniture appeared clean and in good repair. LPA observed the thermostat at a comfortable temperature of 72°F.
The fire extinguishers were observed by the entrance and by the kitchen fully charged and last serviced on 08/22/2022.

Smoke/Carbon Monoxide detectors: Smoke detectors are interconnected and were tested at 2:16 p.m. LPA observed them to be functioning properly. There are two carbon monoxide detectors one downstairs and one in the hallway upstairs by the bedrooms. They were also tested and appeared to be functioning properly.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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
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: 12/20/2022
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Laundry Room: LPA observed a washer and dryer in the laundry room. Washer and dryer were observed to be functioning properly.

Hallway Closet: LPA observed a locked hallway closet where cleaning supplies, extra toiletries and paper towels are stored. LPA observed an extra bedroom closet with PPE supplies.

Bedrooms: There are four bedrooms designated for client use. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens.

Bathrooms: There are three bathrooms designated for client use. One downstairs and two upstairs, One bathroom is located in a single bedroom designated for one client only. All bathrooms were well lit, and clean. LPA observed a sufficient supply of hand soup and paper towels. At approximately 2:25 p.m. water temperature in the downstairs bathroom was measured between 105 and 120 degrees Fahrenheit.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gate was observed closed but unlocked. There is appropriate outdoor seating with shade for clients. LPA observed one shed in the backyard. Shed is being used for storage.

Medications/ Resident file: LPA observed client medications, client files, a first aid kit and emergency food supply locked in closet by the kitchen inaccessible to residents.

No deficiencies were observed during todays visit and the facility is currently following their infection control plan.



Exit interview conducted and report issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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