197610169-9-27-2022-31-AS-SSTS-CJNPJ6-20220927112102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610169
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:21:26 AM

Document Has Been Signed on 09/27/2022 11:21 AM - 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:	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: 3	DATE:	09/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Kesha Richardson, Licensee		TIME COMPLETED:	11:35 AM

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	Licensing Program Analyst (LPA) Shira Stamps met with Administrator Kesha Richardson for an unannounced one (1) year Required visit for this facility. LPA arrived at 9:50 am and was greeted by the Licensee. Two (2) residents were observed in the dining room finishing up breakfast. The other resident was observed to be in their room reading. LPA informed the Licensee of the purpose of the visit. Infection control: The Licensee stated the mitigation plan, infection control plan, and monkey pox plan was sent to Sacramento. LPA requested the plans to be sent to the case carrying LPA. Upon arrival LPA was screened by the Licensee and asked all infection control questions. LPA was asked to sign-in and sanitizer was available. A tour of the physical plant was conducted with Licensee at 10:27 am. The facility has seven(7) bedrooms and three (3) bathrooms currently occupying three (3) residents. One (1) bathroom and one (1) bedroom is designated for staff use only and the facility has awake staff at night. The facility is Fire Cleared for six (6) non-ambulatory, one (1) bedridden, and six (6) hospice residents. The Licensee stated the facility currently has no bedridden or hospice residents. Living and dining LPA observed the living room to be neat and clean along with the dining room and family room. The facility maintains a comfortable temperature at 78°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:00 am. There are two (2) fire extinguishers, one (1) is located in the family room and one (1) is located in the entry way. Fire extinguishers were observed to be full and last serviced on 09/23/21. CONTINUED...

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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: BEYOND A HOME LLC	FACILITY NUMBER: 197610169
	VISIT DATE: 09/27/2022

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The Licensee stated they are set for an annual service through Fletcher’s Fire Protection. Fletcher Fire Protection is short staffed and are behind on their annual services for their customers. Medication closet was located in the hallway and at 10:30 am; was observed to be locked and inaccessible to residents in care.

Food Inspection
LPA conducted a tour of the kitchen around 10:30am 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. LPA observed all knives and sharp object being locked and inaccessible to residents in care.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. LPA tested the exit doors auditory system and it was observed to be operational for each room.

Bathrooms
At 10:35 am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 107.0 degrees F.

Laundry
LPA observed chemicals/hazardous items in the locked laundry room.

Physical environment
LPA toured the outside area of the facility at 10:42 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.
Garage
LPA observed the garage to be attached to the facility and currently being used for storage and an extra refrigerator.
Administrative: LPA collected the LIC.500 and resident roster. Annual fee is current. LPA reminded the Licensee to maintain all resident and staff records. LPA reviewed over fire clearance, bedridden regulation, staff training files, and resident records. An exit interview was conducted, and a copy of this report was given to the Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC809 (FAS) - (06/04)

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