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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604188
Report Date: 07/27/2023
Date Signed: 07/27/2023 11:37:47 AM

Document Has Been Signed on 07/27/2023 11:37 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
SAN DIEGO RO, 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:
07/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rose Sams, LicenseeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit and concurrently conducted a case management visit to the facility and provided Technical Advisory’s (TA). LPA Lopez identified herself and was granted entry by Fred Sams, Administrator. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Administrator Sams. Licensee Rose Sams and Administrator Leilani Sams later arrived and joined the visit.

During the visit, LPA requested and obtained records. In review of records, LPA observed that client #1 (C1 - see LIC811 Confidential Names list) did have an IPP and Needs and Service Plan. Records show the facility has been providing C1 with behavioral services. LPA reviewed Title 22, Division 6, Chapter 1 and 6, Article 6, Section’s: 85068.1 Admission Procedures, 80068.2 Needs and Service Plan, 85068.3 Modifications to Needs and Service Plan, 85068.5 Eviction Procedures, 85122 Emergency Intervention Plan, 85165 Emergency Intervention Staff Training, and 85161 Emergency Intervention Documentation, with Licensee and Administrator's Sams'. Technical Advisory notices were given during today’s visit. No deficiencies were cited.

An exit interview was conducted with Licensee and Administrators' Sams'. A copy of this report, Confidential Names list (LIC 811) and Applicant/Licensee Rights (LIC 9058 03/22) were provided to Licensee Sams at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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