197610105-5-17-2022-31-AS-SSTS-CEHTX7-20220517150640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610105
Report Date: 05/17/2022
Date Signed: 05/17/2022 03:07:13 PM

Document Has Been Signed on 05/17/2022 03:07 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:	MELONIE & JESSIE JAMES JR. ARF		FACILITY NUMBER:	197610105
ADMINISTRATOR:	LEWIS, JESSICA		FACILITY TYPE:	735
ADDRESS:	43505 ELITE LANE		TELEPHONE:	(661) 466-7049
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS: 0	DATE:	05/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Jessica Lewis, Administrator		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 1:45pm, Licensing Program Analyst (LPA) Shira Stamps arrived at the above facility for an unannounced one (1) year Required visit. LPA was greeted by the Administrator, and LPA informed the Administrator of the purpose of the visit. The facility currently has no clients. Infection control: LPA reviewed facility mitigation plan (approved on 05/04/22) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the Administrator and sanitizer was made available. A tour of the physical plant was conducted with the Administrator at 1:55pm. The facility has five (5) bedrooms and three (3) bathrooms currently occupying no clients. One (1) bedroom and one (1) bathroom is designated for staff use only. Food Inspection LPA conducted a tour of the kitchen around 2:00pm 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 care clean and inaccessible to pests. LPA observed knives, sharp objects, and medications locked in the kitchen draw. Laundry LPA observed the laundry room. The Administrator stated the laundry room will be locked. There are two (2) fire extinguishers located in the laundry room. The Fire extinguishers were observed to be full. CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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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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: MELONIE & JESSIE JAMES JR. ARF	FACILITY NUMBER: 197610105
	VISIT DATE: 05/17/2022

NARRATIVE

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Living and dining
At 1:58pm, LPA observed the living room and family room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 79°F. The smoke detectors and carbon monoxide detector were tested and observed to be operational at 2:16pm.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident.

Bathrooms
At 2:16pm LPA observed all bathrooms to have non-skid matts, and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 109.9 degrees F.

Garage
At 2:10pm, LPA observed the attached garage and currently being used for storage.

Physical environment
LPA toured the outside area of the facility at 2:12pm. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. A pool is on the premises, and is locked at all times.

Administrative: Annual fee is current.

An exit interview was conducted. A copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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