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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610391
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:49:47 PM

Document Has Been Signed on 10/19/2023 12:49 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:J6 ADULT HOMEFACILITY NUMBER:
197610391
ADMINISTRATOR:NARAJOS, EARLYNNFACILITY TYPE:
735
ADDRESS:1151 WEST AVENUE J6TELEPHONE:
(818) 859-3796
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: DATE:
10/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Earlynn NarajosTIME COMPLETED:
01:15 PM
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On 10/19/2023, Licensing Program Analysts (LPAs) Lorena Casillas and Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with applicant Earlynn Narajos. This is an initial application for an adult residential care facility. A fire clearance dated 02/10/2023 was received for four (4) ambulatory residents. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 9:47 am until 11:13 am with applicant.
Today’s site visit consisted of LPAs touring the physical plant inside and outside with the applicant from 11:23 am until 11:50 am. LPAs observed the following:

Facility has a functional fire extinguisher. There is a functioning telephone on the premises. The facility phone number 661-802-7583 Emergency exit plan/sketch is posted on the living room wall and the family room wall along with other posting requirements. The smoke detectors were checked at 11:47 am and were functional. The carbon monoxide detector was also functional. The water temperature was measured at 12:40pm and was at 105.7 degrees F.

There are four (4) resident bedrooms (four (4) single bedrooms). LPAs observed bed linens, chest of drawers, closet, night stand, and lamp in each bedroom. The bedrooms were neat and clean.

The facility office is contained in the family room. The staff files will be locked in file cabinet located in family room.

The common areas (living room, family room, kitchen, and dining areas) were appropriately furnished, and lighting was adequate. The living room contained comfortable seating. The family room was furnished with magazines, comfortable seating, and a television.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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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