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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610169
Report Date: 10/22/2024
Date Signed: 10/22/2024 04:04:00 PM

Document Has Been Signed on 10/22/2024 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BEYOND A HOME LLCFACILITY NUMBER:
197610169
ADMINISTRATOR/
DIRECTOR:		RICHARDSON, KESHAFACILITY TYPE:
740
ADDRESS:6023 WEST AVE L 12TELEPHONE:
(661) 860-5048
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 6DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Kesha Richardson and Lakesha MackeyTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Evelin Rios arrived at the facility above to conduct an annual required visit. LPA was greeted and granted access by staff #1 (S1). S1 contacted the administrator Kesha Richardson and informed them LPA was at the facility. LPA spoke with the Administrator via telephone and explained the reason for the visit. Administrator met LPA at approximately 12:10 p.m. The facility has an approved fire clearance for six (6) non ambulatory residents of which one (1) may be bedridden. Facility has a Hospice waiver for six (6). Administrator could not stay until the end of todays visit and designated Lakesha Mackey, caregiver lead to sign todays report.

At 11:45 a.m. LPA conducted a tour of the physical plant of the facility inside and out and the following was observed:

Common Areas: These include two (2) sitting areas and a dining area. Areas were observed clean and clear of clutter. There is a fire place in one of the sitting areas that was adequately screened. The dining table sits the capacity of the facility. There are two fire extinguisher observed fully charged with service date 09/04/2024.

Kitchen: The kitchen was observed clean and clear of clutter with a sufficient supply of two-day perishable and seven-day non-perishable foods; properly stored. LPA observed the knives and sharp objects located in a locked kitchen drawer inaccessible to residents in care.

Bathrooms: LPA toured two (2) resident bathrooms. All bathrooms were observed with non-skid matts, grab bars, toilet paper, paper towels and hand soap. Hot water was tested at 3:08 p.m. and measured between 117.4 to 119.4 degrees Fahrenheit, within regulation.
(Continued to LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BEYOND A HOME LLC
FACILITY NUMBER: 197610169
VISIT DATE: 10/22/2024
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Bedrooms: LPA toured six (6) resident bedrooms. LPA observed rooms to have appropriate bedding and lighting. There is a night stand and sufficient storage. LPA tested the auditory alarms on the exit doors in the bedrooms and they were observed operational.

Outside: LPA toured the outside area of the facility and observed appropriate outdoor furniture, with a covered shaded area for residents. LPA observed a locked shed used for storage. No bodies of water on the premises.

LPA observed smoke detectors through out the facility. Smoke detectors are hard wired and interconnected. At 2:35 p.m. Lakesha tested a smoke detector. Smoke detectors were observed functioning properly. Lakesha tested a carbon monoxide detector located by the kitchen at 2:37 p.m. and it was observed operational.

Resident and Staff Files: From approximately 12:35 p.m. to 2:30 p.m. LPA reviewed resident and staff files. LPA conducted a file review of six (6) out of six (6) resident records to insure compliance of licensing forms. LPA also conducted a file review of three (3) staff records to insure forms and training are up to date and in compliance with licensing forms. LPA reviewed certificate of liability insurance, emergency disaster training, LIC 500 and the facility program.

Medications: At approximately 2:45 p.m. LPA reviewed Medication and Medication Records. LPA observed centrally stored medications locked in a closet by the kitchen. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR). LPA also observed a complete first aid kit with manual.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, there were no deficiencies observed during today's visit. Exit interview conducted. Copy of the report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
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