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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610076
Report Date: 10/01/2024
Date Signed: 10/01/2024 03:55:04 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/01/2024 03:55 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELEVATED HOME HEALTHFACILITY NUMBER:
197610076
ADMINISTRATOR/
DIRECTOR:		GOODWIN, BYRANISHAFACILITY TYPE:
740
ADDRESS:44663 2ND STREET EASTTELEPHONE:
(702) 823-8166
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 2CENSUS: 0DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Byranisha GoodwinTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 10/01/2024 Licensing Program Analyst (LPA) Lorena Casillas, met with Administrator Byranisha Goodwin for a One (1) year Required visit for this facility.

A tour of the physical plant was conducted with the Administrator at 2:00 pm. The facility has three (3) bedrooms and two (2) bathrooms. One (1) bedroom is designated for residents and two (2) bedrooms for personal use. The facility currently has no residents. The tool kit was not used as there are no residents in the home.

Infection control: LPA reviewed facility mitigation plan (approved on 03/30/2021) to make sure licensee was following current infection control recommendations.

Kitchen: LPA conducted a tour of the kitchen at 2:10 pm and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Medication and knives stored in a locked hallway closet. First aid kit furnished and fully equipped.

Living/dining/family: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 2:30 pm. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 10/30/2023.

Bedrooms: LPA observed resident room to have the appropriate bedding. There is a nightstand and sufficient lighting. LPA observed sufficient linens and towels in the hallway closet.


Continued on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATED HOME HEALTH
FACILITY NUMBER: 197610076
VISIT DATE: 10/01/2024
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Bathrooms: LPA observed bathroom was clean, with soap and paper towels for clients. Hot water was tested in the client bathroom and measured at 114.6 degrees Fahrenheit.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The gate was unlocked and easily accessible. There is a patio umbrella and patio furniture for residents to use. Garage entrance was locked and secure. Garage contains laundry area and a freezer, chemicals and household supplies locked and stored in the garage.

Administrative: LPA requested a copy of liability insurance and Administrator certificate. Documents will be emailed to LPA. Annual fees are current.

Resident and Staff Files: There are currently no residents or staff.



Staff and Resident Interviews: There are currently no residents. Interviews were not conducted.

No deficiencies were observed, an exit interview was conducted, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
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