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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608857
Report Date: 03/15/2022
Date Signed: 03/15/2022 02:10:21 PM

Document Has Been Signed on 03/15/2022 02:10 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:SARA'S HOME AWAY FROM HOMEFACILITY NUMBER:
197608857
ADMINISTRATOR:DANIEL D. CHOFACILITY TYPE:
740
ADDRESS:23820 VIA JACARATELEPHONE:
(661) 388-4464
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY: 6CENSUS: 5DATE:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rommel Catajay, StaffTIME COMPLETED:
02:30 PM
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At 12:45pm Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by Staff #1 (S1), who granted access to the facility. Administrator was contacted over the phone and LPA explained the reason for the visit.

At 1:00pm, LPA conducted a tour of the facility and the following was observed:

Infection control: LPA reviewed the facility mitigation plan (approved on 04/15/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. S1 stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: At approximately, 1:00pm LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. At approximately, 1:05pm LPA observed medications are centrally stored and locked in the kitchen cabinet and inaccessible to residents in care.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: At 1:20pm LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 120°F.


Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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: SARA'S HOME AWAY FROM HOME
FACILITY NUMBER: 197608857
VISIT DATE: 03/15/2022
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 LPA observed appropriate grab bar and non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom.

Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Facility has two (2) fire extinguishers; one (1) in the kitchen and one in the living room. Both fire extinguishers were last serviced on 03/17/21.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:25pm they were tested and observed to be operational

Outside areas: At approximately, 1:30pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: Laundry area is located in an attached garage and kept locked and inaccessible to residents. Extra PPE supplies and food storage was also observed.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC809 (FAS) - (06/04)
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