197603505-1-5-2022-31-AS-ADUA-CAE2VZ-20220105164447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603505
Report Date: 01/05/2022
Date Signed: 01/05/2022 04:46:04 PM

Document Has Been Signed on 01/05/2022 04:46 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LARC ELDERLY HOME I		FACILITY NUMBER:	197603505
ADMINISTRATOR:	BRATZEL, CHRISTINE		FACILITY TYPE:	740
ADDRESS:	29896 BOUQUET CANYON ROAD		TELEPHONE:	(661) 296-8636
CITY:	SAUGUS	STATE: CA	ZIP CODE:	91350
CAPACITY: 15		CENSUS: 13	DATE:	01/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kathleen Sturkey, Executive Director		TIME COMPLETED:	11:45 AM

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) Abeye Duguma met with the Executive Director, Kathleen Sturkey, for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00am and the following was noted:
There are two entrances being utilized at the facility, there are required posters posted at the main door. Screening areas are located immediately upon entrance. Sign in sheets, infrared thermometers, hand sanitizers, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The campus has multiple outdoor shaded area for residents and visitors. The facility has sufficient stock of PPE in storage closets located near the entrances. The facility has a total of ten (10) bedrooms, of which two (02) are for staff and six (06) bathrooms for both residents and staff. The facility is fire cleared for eight (08) non-ambulatory residents. The facility is currently occupying five (05) non-ambulatory residents and eight (08) ambulatory. The facility has a swimming pool that is fenced and locked. Laundry detergents, cleaning agents and other toxins are stored in locked laundry rooms. Kitchen areas are sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.
(continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LARC ELDERLY HOME I	FACILITY NUMBER: 197603505
	VISIT DATE: 01/05/2022

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

Knives and sharps are observed to be locked in a kitchen cabinets inaccessible to residents. Living and dining room furniture were also checked. The living rooms are neat and clean along with the dining room. The facility maintains a comfortable temperature at 71°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located in the kitchens and hallways observed to be full and last inspected on 04/07/2021. Staff rooms were observed to be locked. No medications are observed in staff rooms. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathrooms were checked for cleanliness and proper operations. The hot water temperatures was measured between 112.2-114.1°F. Towels and washcloths are not shared. There was enough clean linen available storage closets located near the front entrance. LPA observed medications and first aid kits to be locked and inaccessible to residents, located in the kitchen.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2