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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604188
Report Date: 03/02/2023
Date Signed: 03/02/2023 05:18:02 PM

Document Has Been Signed on 03/02/2023 05:18 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:R&A HOMESFACILITY NUMBER:
374604188
ADMINISTRATOR:SAMS, ROSEFACILITY TYPE:
735
ADDRESS:1670 BAKERSFIELD STTELEPHONE:
(619) 962-8009
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 4CENSUS: 4DATE:
03/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Co-Administrator Lelani SamsTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Co-Administrator Lelani Sams. LPA also met with Licensee Rose Sams, who arrived later during the visit.

Today's visit was in response to an LIC624 Unusual Incident/Injury Report, which licensee self-submitted to the CCLD San Diego Regional Office on 02/15/2023. The report described Client #1 (C1) having a challenging behavioral incident at an off-site day program on 12/09/2023, for which R&A Homes staff helped respond to. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a facility tour / welfare check, collected records, interviewed staff, and provided technical assistance. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with both Sams, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2023
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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