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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610332
Report Date: 05/24/2024
Date Signed: 05/24/2024 11:42:47 AM

Document Has Been Signed on 05/24/2024 11:42 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEOPLE'S CARE LANCASTER C12FACILITY NUMBER:
197610332
ADMINISTRATOR/
DIRECTOR:		CORTES, CRYSTALFACILITY TYPE:
738
ADDRESS:8543 W AVENUE C12TELEPHONE:
(909) 287-3557
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 0DATE:
05/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Crystal Cortez (Administrator), Sharon Han (Applacant)TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection and met with the Administrator, Crystal Cortez and Applicant Sharon Han. An application to operate a Community Crisis Home - Adult Residential Facility was received by Community Care Licensing (CCL) on 8/12/2022. A fire clearance was approved on for a maximum capacity of four (4) adults of which one (1) can be ambulatory and three (3) non ambulatory.

A tour of the physical plant inside and out was initiated at 9:30 a.m. The facility is a one (1) story single family home. The following observed:

COMMON AREAS: These consist of two (2) dining areas, three (3) living/family areas and game rooms in the garage and in an area behind the kitchen. All common rooms were clean and clear of clutter, appropriately furnished to accommodate a maximum capacity of four (4) clients.

KITCHEN: There were sufficient supplies of both cook ware and dining ware as well as a 7 day supply of non perishable food to accommodate the capacity of clients. The appliances and fixtures appeared clean, sanitary and functional. LPA observed cleaning products locked under the sink. LPA observed sharps locked in the kitchen drawers.

BEDROOMS: There are four (4) private bedrooms designated for client use. All bedrooms are furnished with beds, dressers, required bedding, linens, sufficient closet space, and lighting. The facility has hallway closets with extra linens and toiletries.

(Continue on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEOPLE'S CARE LANCASTER C12
FACILITY NUMBER: 197610332
VISIT DATE: 05/24/2024
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(Continued from LIC809)
BATHROOMS: All bathrooms had functional fixtures and were properly supplied with hand soap, toilet paper, and paper towels. Hot water was tested in three (3) out of three (3) bathrooms. Hot water temperature measured between 105 and at 120.0 degrees F within range.

LAUNDRY ROOM: The laundry room is located by the kitchen accessible to clients. The washer/dryer appear to be operational. LPA observed where the detergents and chemicals will be kept locked and inaccessible to clients in care.

GARAGE: The garage is a designated game room that is accessible to clients. In the garage there is an extra refrigerator, emergency food, emergency water and emergency backpacks for the capacity of the facility.

OFFICE/MEDICATION ROOM: The medication room is located by the kitchen and is kept locked and inaccessible to clients in care. The medication will be kept locked in a medication cart. In the room the facility will store facility and client records in a locked filing cabinet. LPA observed the facility telephone to be operational.

SURROUNDING GROUNDS: The entrance to the home is gated. Two gates to enter and exit the facility have approved delayed egress. The driveway serves as a large parking lot for guests. The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients and outdoor activities for the clients stored in a bench.

Component III Orientation with the Administrator and Applicant was also conducted during the visit.

Pre-Licensing is complete and this facility has no deficiencies. Today’s report will be sent to CAB.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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