<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530021
Report Date: 11/30/2023
Date Signed: 11/30/2023 01:18:06 PM

Document Has Been Signed on 11/30/2023 01:18 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Lanee Tate- AdministratorTIME COMPLETED:
01:27 PM
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) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Lanee Tate and was granted entry to the facility.

The facility is an Adult Residential Facility (ARF) level 4i home vendorized by Inland Regional Center. The facility is a three (3) bedroom, two (2) bathroom home with a kitchen/dining area, living room, and an attached garage. The facility is licensed for a capacity of three (3) ambulatory clients and the current census is zero (0) clients. The facility is currently waiting on client placement from Inland Regional Center. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: There are no obstructions to the indoor and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 110 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible for future clients in care. There was a designated storage space for future client files and staff files. Medications will be kept in the medication cabinet in the kitchen inaccessible to future clients. Overall, the facility is clean, in good repair, and operating in safe conditions to accept clients.

Food Service: Non-perishable and perishable food supply is sufficient.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SYCAMORE HOUSE
FACILITY NUMBER: 335530021
VISIT DATE: 11/30/2023
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
26
27
28
29
30
31
32
Care & Supervision: There are no clients in care to supervise.

Record Review: LPA reviewed one (1) staff file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. There are no client files or medications/MARs records to audit.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Lanee Tate.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2