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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607020
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:29:52 AM

Document Has Been Signed on 06/21/2022 11:29 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JOE-SEPHINE RESIDENTIAL CARE FAC. FOR THE ELDERLYFACILITY NUMBER:
197607020
ADMINISTRATOR:JOSEPHINE C. SANOYFACILITY TYPE:
740
ADDRESS:615 CURVE CIRCLETELEPHONE:
(661) 942-4307
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 3DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joesphine Sanoy, LicenseeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Shira Stamps arrived at the facility for an unannounced one (1) year Required visit. LPA arrived at 10:00 am, and was greeted by Licensee Josephine, LPA informed the Licensee of the purpose of the visit. LPA observed two residents watching TV the living room.

A tour of the physical plant was conducted with the Licensee at 10:10 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for three (3) non-ambulatory, one bedridden, and a hospice wavier for one. The facility currently has one (1) ambulatory and two (2) non- ambulatory residents.

Infection control: LPA reviewed the mitigation plan approved on 3/20/21. The Licensee emailed the infection control plan on 6/16/22. The LPA still needs to review for approval. The facility is following current infection control recommendations. Upon arrival LPA was screened by the Licensee and asked all infection control questions. LPA was asked to sign-in and sanitize hands.

Food Inspection
LPA conducted a tour of the kitchen around 10:10 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. The medication cabinet was also observed to be locked. Cleaning supplies and chemicals were observed to be locked under the kitchen sink.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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: JOE-SEPHINE RESIDENTIAL CARE FAC. FOR THE ELDERLY
FACILITY NUMBER: 197607020
VISIT DATE: 06/21/2022
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Living and dining
At 10:15 am, LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:15 am. There one (1) fire extinguisher located in the living room. The Fire extinguisher was observed to be full and last serviced 6/10/22.

Garage/Laundry
At 10:23 am, LPA observed the garage to be attached to the facility and is currently being used for storage. LPA observed a refrigerator and deep freezer in the garage. The Laundry room is located in the garage. All chemicals/hazardous items were observed to be locked in a cabinet.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. All alarms on the exit doors are functional.

Bathrooms
LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 10:29 am and measured within regulation at 116.3 degrees F.

Physical environment
LPA toured the outside area of the facility at 10:22 am. LPA observed a covered shaded area for residents. No bodies of water on the premises. LPA observed all tools in a locked gated area.

Administrative: Annual fee is current.

An exit interview was conducted, and a copy of this report was given to the Licensee.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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