197610169-9-16-2021-31-AS-APAA-C6WQ9K-20210916115828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610169
Report Date: 09/16/2021
Date Signed: 09/16/2021 11:59:49 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:	BEYOND A HOME LLC		FACILITY NUMBER:	197610169
ADMINISTRATOR:	RICHARDSON, KESHA		FACILITY TYPE:	740
ADDRESS:	6023 WEST AVE L 12		TELEPHONE:	(661) 860-5048
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 0	DATE:	09/16/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kesha Richardson, Administrator		TIME COMPLETED:	12:15 PM

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At 10:00am Licensing Program Analysts (LPAs), Angela Panushkina, Shira Stamps and Licensing Program Manager (LPM), Nichelle Gylliard conducted an announced Pre-Licensing visit to the above facility and met with applicant Kesha Richardson. LPA team conducted an entrance interview with the Administrator. Fire Clearance dated 06/16/2021 was received for five (5) non-ambulatory, hospice waver for six (6) and one (1) bedridden residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPAs touring the physical plant inside and outside and observed the following:

The facility has a total of seven (7) bedrooms, six (6) of which are designated for resident use. Resident bedrooms were observed to be appropriately furnished. There are two (2) bathrooms in the facility designated for resident use and were observed to have non-skid mats and appropriate grab bars installed. The facility will have awake staff at night and one (1) bedroom and one (1) bathroom is designated for staff use only.

The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television, comfortable furniture and the fireplace is adequately screened.. Resident and staff records will be stored in a locked cabinet in the office (Admin. suite). The fire extinguishers are located in the kitchen and laundry area. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:00am they were tested and observed to be operational. At 10:30am the hot water was tested and measured at 121°F. LPA advised the applicant to adjust the hot water tank. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the entrance wall with other posting requirements. Medications are stored in a locked closet in the living room area. The first aid kit is readily available.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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: BEYOND A HOME LLC	FACILITY NUMBER: 197610169
	VISIT DATE: 09/16/2021

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Facility appears to be clean, in good repair and kept at a comfortable temperature of 77°F. Appliances in the kitchen appeared to be functional. LPA team observed enough sufficient supply of 2 days perishable foods and one week of non-perishable foods on premises. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors.

There is a shaded sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The attached garage is kept locked. The garage is currently being used for perishable and non-perishable food storage and PPE storage. At approximately, 10:45am LPA team toured through the laundry area and observed all chemicals and cleaning supplies area locked and inaccessible to residents in care.

Component III was conducted with the administrator. Community Care Licensing Department (CCLD) will be notified once facility admits their first resident.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Administrator Kesha Richardson and a copy of this report was provided.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC809 (FAS) - (06/04)

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