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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880989
Report Date: 04/13/2022
Date Signed: 04/13/2022 11:18:36 AM

Document Has Been Signed on 04/13/2022 11:18 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:PEOPLE'S CARE SYCAMOREFACILITY NUMBER:
361880989
ADMINISTRATOR:ZIA MIERE PICKENSFACILITY TYPE:
737
ADDRESS:17358 SYCAMORE LANETELEPHONE:
(760) 961-1014
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 2DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Administrator Zia Miere PickensTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility for an annual inspection. LPA met with Administrator Zia Miere Pickens.

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients.

LPA toured the facility inside and out and there were no health and safety concerns. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The outdoor and indoor hallways were also free of obstruction.

Cleaning supplies are locked in the garage in a cabinet. Residents medications were kept in a safe and locked closet in the laundry room.

The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review.

The client rooms had the required furniture and sufficient lighting. There were handrails in all bathrooms to accommodate the needs for bathing and showers have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature in the client bathroom. The hot water temperature measured at 102.5 degrees F.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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: PEOPLE'S CARE SYCAMORE
FACILITY NUMBER: 361880989
VISIT DATE: 04/13/2022
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LPA observed hand sanitizer throughout the facility and a 30- day supply of PPE. All clients have at least a 30 -day supply of medications. LPA observed that all emergency contact information for the clients have been updated.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC809 (FAS) - (06/04)
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