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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610076
Report Date: 10/26/2022
Date Signed: 10/26/2022 12:42:33 PM


Document Has Been Signed on 10/26/2022 12:42 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
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:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Byranisha GoodwinTIME COMPLETED:
12:15 PM
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At 11:00 a.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA knocked on the doorbell twice, and no one answered. LPA called the Administrator, and the Administrator stated she was outside and did not hear the doorbell.

At this time, facility has no residents in care. This is a three bedroom, two bathroom facility. Out of the three bedrooms, one is designated for resident use, and has two beds. LPA conducted a physical plant tour and observed the following:

Some covid-19 signage was observed along the hall and hand washing signs were posted in the bathrooms. Facility maintains linens, a first aid kit, and chemicals in a locked closet in the hallway. LPA toured the kitchen and observed a broken cabinet door and observed the exterior of the refrigerator to be dirty, with drippings and smudge marks all over. LPA observed a fire extinguisher with a service date of 10/11/2022. LPA toured the backyard and observed dog feces and urine throughout the backyard. LPA had a verbal conversation with the Administrator about this issue, to which the Administrator stated when she gets residents, she will remove the dogs from the property.

Deficiencies issued, per CA Code of Regulations, Title 22. Appeal rights issued. Exit interview conducted, report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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Document Has Been Signed on 10/26/2022 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HEALTH
FACILITY NUMBER: 197610076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which LPA observed a broken cabinet door in the kitchen, a refrigerator to be dirty with drippings and smudge marks, and dog feces and urine in the outside walkway that leads to the backyard. This poses a potential health and safety or personal rights risk to residents in care.
POC Due Date: 11/02/2022
Plan of Correction
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The Administrator/Licensee will fix the broken cabinet door in the kitchen, clean the refrigerator, and clean the walkway that leads to the backyard. Photos documenting the items mentioned above cleaned/repaired will be submitted to LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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