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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530021
Report Date: 09/29/2022
Date Signed: 09/29/2022 10:22:01 AM

Document Has Been Signed on 09/29/2022 10:22 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:SYCAMORE HOUSEFACILITY NUMBER:
335530021
ADMINISTRATOR:TATE, LANEEFACILITY TYPE:
735
ADDRESS:29104 SYCAMORETELEPHONE:
(909) 969-0068
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 3CENSUS: 0DATE:
09/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Lanee TateTIME COMPLETED:
10:23 AM
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Licensing Program Analyst (LPA) Anna Bueno made an announced visit to the facility in order to conduct a pre-licensing inspection for an initial application. LPA Bueno identified herself to licensees, Derek Newson-Thompson and Lanee Tate, and advised them of the purpose of the visit.

The facility has a total of three bedrooms, two bathrooms, three of which are clients, kitchen, a great room for dining and sitting, a loft space for staff and office area, and backyard. The facility has been granted a fire clearance on 6/28/2022 by the Lake Elsinore Office of the Fire Marshal for a total capacity of three ambulatory clients.

LPA and Licensee Tate toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded seating area for clients. LPA observed that side gate is unlocked and free of obstruction. The facility has a working telephone for client use. The facility has charged fire extinguishers, and functioning combination smoke and carbon monoxide alarms. The facility had a complete first aid kit and manual. There are locked centralized storage areas for medications, cleaning supplies, and sharps. The following were observed of the physical plant:

Bedrooms: LPA observed all bedrooms to have the required bedding and furniture, such as, clean mattresses and linen, sufficient storage space, chairs, and lighting.
Bathrooms: LPA observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients.
Kitchen: LPA inspected the kitchen and found cleaning supplies and sharps were kept in a safe and secured place. Dishes, glasses, and utensils were in good repair and stored in a

**************************CONTINUED ON LIC 812C**************************
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SYCAMORE HOUSE
FACILITY NUMBER: 335530021
VISIT DATE: 09/29/2022
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safe manner. LPA observed a two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The facility menu was available for review. The kitchen countertop, floors, and appliances were free from debris.
Great room: LPA observed adequate seating in the dining table and in the sitting areas. in the common areas. The facility had a supply of activities for the clients.

LPA observed that the physical plant is clean, in good repair, and appeared hazard-free during today's visit. LPA has determined that the facility is meeting operational requirements for current clients. LPA Bueno completed COMP III with the Licensees at the conclusion of the inspection.

The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted where this report was discussed and a copy was provided to Derek Newson-Thompson and Lanee Tate at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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