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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609885
Report Date: 12/27/2023
Date Signed: 12/28/2023 08:08:22 AM

Document Has Been Signed on 12/28/2023 08:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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:
12/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Leslie Clarkson- AdministratorTIME COMPLETED:
03:30 PM
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This case management visit is conducted by the Licensing Program Analyst (LPA) Leslie Ngo-Castaneda in conjunction with complaint investigation visit to address the issues unrelated to the complaint.
On 12/26/23 while LPA was conducting complaint investigation, at 10:50am, LPA reviewed facility staff schedule and noted that as per schedule during day time, there should be 2 staff present at the facility.
Further investigation revealed that on 12/21/23 and at the time of this visit, there was only one (01) staff present at the facility.
Therefore, based on the interviews and record review it was concluded that at least in two occasions, the facility has insufficient staffing.
Under Title 22 Regulations, the following citation is issued and recorded on LIC809D.
No immediate health and safety hazard is noted at the time of this visit.

Exit interview was conducted. Appeal rights discussed and a copy of report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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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Document Has Been Signed on 12/28/2023 08:08 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 12/27/2023 at 02:47 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: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2023
Section Cited
CCR
80065(a)

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Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs This requirement is not met as evidenced by.
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Licensee will provide updated LIC 500 to ensure staffing in the facility.
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Licensee did not ensure to have sufficient number of qualified personnel to assist facility residents. Number of staff present at the facility was not as per facility schedule. This possess potential health and safety risk to residents in care.

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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023


LIC809 (FAS) - (06/04)
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