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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608857
Report Date: 02/24/2024
Date Signed: 02/24/2024 04:04:56 PM

Document Has Been Signed on 02/24/2024 04:04 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: 2DATE:
02/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Marc KrauseTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with, caregiver, Marc Krause for a Required One (01) Year visit. LPA explained the reason for the visit. The administrator, Daniel Cho, designated Marc Krause to sign and accept this report. A tour of the physical plant was conducted at around 1:00 PM and the following was noted:

There is one entrance being utilized at the facility. The facility has a total of four (04) bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for two (02). The facility is currently occupying two (02) residents.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away.

Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

The living and dining room are neat and clean. The facility maintains a comfortable temperature at 72°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen, observed to be full and last inspected on 03/28/2023.

(continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2024
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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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: 02/24/2024
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The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 112.7°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

LPA observed medication and first aid kit to be locked and inaccessible to residents.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2024
LIC809 (FAS) - (06/04)
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