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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610076
Report Date: 09/25/2020
Date Signed: 09/25/2020 11:10:56 AM

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:ELEVATED HOME HEALTHFACILITY NUMBER:
197610076
ADMINISTRATOR:GOODWIN, BYRANISHAFACILITY TYPE:
740
ADDRESS:44663 2ND STREET EASTTELEPHONE:
(702) 823-8166
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:2CENSUS: 0DATE:
09/25/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Byranisha GoodwinTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted a second and final pre-licensing visit to the facility and met with the Applicant/Licensee Byranisha Goodwin at 10:10 am. While entering the facility LPA observed the COVID-19 signs posted on the front door. LPA was instructed by Applicant/Licensee to sign in, use the hand sanitizer and paper towels to clean hands. Applicant/Licensee recorded LPA’s temperature. LPA explained the purpose of the visit was to complete final inspection of the facility.

LPA Spaeth and Applicant/Licensee toured the facility to view the updates that were completed by Applicant/Licensee. Upon entering the kitchen, LPA observed the small lower cabinet which contained a missing drawer had been removed. LPA Spaeth and Applicant/Licensee then entered the first bathroom. LPA observed the missing tile piece had been properly replaced with a new tile piece and the cabinet under the bathroom sink did not contain cleaning supplies. LPA Spaeth and Applicant/Licensee then entered the master bedroom designated for two residents. LPA Spaeth observed the bedroom door leading to the front yard was set up with the proper signal alarm and the bedroom closet was available for resident's personal clothing. At 10:20 am. Applicant opened the door and the alarm properly sounded. LPA and Applicant/Licensee went to the backyard. LPA observed the following items had been removed from the backyard: automobile tires, cement blocks, the wire, and tree limbs. LPA Spaeth observed a new apple tree planted in the backyard to provide enjoyment for residents.

LPA Spaeth confirmed with the Applicant/licensee all items were addressed and completed by the Applicant/Licensee. An exit interview was conducted and a copy of the report was emailed to Applicant/Licensee.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
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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