197610076-3-21-2024-31-AS-LCAS-D3KR6P-20240321124504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610076
Report Date: 03/21/2024
Date Signed: 03/21/2024 12:45:35 PM

Document Has Been Signed on 03/21/2024 12:45 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 HEALTH		FACILITY NUMBER:	197610076
ADMINISTRATOR:	GOODWIN, BYRANISHA		FACILITY TYPE:	740
ADDRESS:	44663 2ND STREET EAST		TELEPHONE:	(702) 823-8166
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	2	CENSUS: 1	DATE:	03/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Byranisha Goodwin		TIME COMPLETED:	01:00 PM

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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 09:10 am. The facility has three (3) bedrooms and two (2) bathrooms. It is currently occupied by one (1) resident.

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 9:15 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables 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 70°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 09:20 am. 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

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELEVATED HOME HEALTH	FACILITY NUMBER: 197610076
	VISIT DATE: 03/21/2024

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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 110.6 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, LIC500, and resident roster, all will be emailed to LPA. Annual fees are current.

Resident Files: LPA conducted a file review of resident records.

Staff Files: LPAs conducted a file review of staff records.

Medications: Resident administers own medication per Physicians report.

Staff Interviews: At 11:57 am LPA interviewed Administrator.

Resident Interviews: At 12:10 pm LPA attempted to interview resident but resident refused to be interviewed.

No deficiencies were observed, an exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC809 (FAS) - (06/04)

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