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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603506
Report Date: 01/05/2022
Date Signed: 01/05/2022 04:48:01 PM

Document Has Been Signed on 01/05/2022 04:48 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 IIFACILITY NUMBER:
197603506
ADMINISTRATOR:BRATZEL, CHRISTINEFACILITY TYPE:
740
ADDRESS:29894 BOUQUET CANYON ROADTELEPHONE:
(661) 296-8636
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY: 8CENSUS: 0DATE:
01/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kathleen Sturkey, Executive DirectorTIME COMPLETED:
02:30 PM
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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 11:40am and the following was noted:
There is one entrances being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, 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 shaded area for residents and visitors. The facility has sufficient stock of PPE in a storage closet located near the entrances. The facility has a total of five (05) bedrooms, of which one (01) is for staff and three (03) bathrooms for both residents and staff. The facility is fire cleared for four (04) non-ambulatory. The facility is currently occupying zero (00) residents. The facility has a swimming pool that is fenced and locked. Laundry detergents, cleaning agents and other toxins are stored in a locked laundry room. Kitchen area is 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)
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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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LARC ELDERLY HOME II
FACILITY NUMBER: 197603506
VISIT DATE: 01/05/2022
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Knives and sharps are observed to be locked in a kitchen cabinet 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 72°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located in the kitchen and hallway 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 116.1°F. Towels and washcloths are not shared. There was enough clean linen available in a storage closet located near the front entrance. LPA observed medications and first aid kit 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)
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