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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604188
Report Date: 03/22/2024
Date Signed: 03/22/2024 10:00:47 AM

Document Has Been Signed on 03/22/2024 10:00 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: 3DATE:
03/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:Administrator Lelani SamsTIME COMPLETED:
08:25 AM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit to re-issue the 809 Case Management report given to Administrator Lelani Sams on 3/21/2022.

On 3/21/2022 Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit with Administrator Fred Sams short time later Administrator Lelani Sams joined the visit.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Fred Sams. A short time later Administrator Lelani Sams joined the visit.

Today's visit was in response to licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 3/18/2024. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 3/16/2024. Administrator Lelani Sams also explained she made phone calls to report the death to CCLD as well as Regional Center. Phone calls were made Saturday 3/16/2024 as well as Monday 3/18/2024.

LPA performed a facility tour / welfare check on remaining clients, collected pertinent records, and interviewed relevant staff. No deficiencies were observed or cited during today's visit.

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

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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