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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600333
Report Date: 07/17/2023
Date Signed: 07/19/2023 07:24:45 PM

Document Has Been Signed on 07/19/2023 07:24 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:C-H #2 COMMUNITY LIVING RESIDENTIAL FACILITYFACILITY NUMBER:
191600333
ADMINISTRATOR:DAVID BERRYFACILITY TYPE:
735
ADDRESS:3220 W 111TH PLTELEPHONE:
(310) 419-7434
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 2DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Elsa RodriguezTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1-year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and LPA temperature was checked. LPA Bunker met with staff Elsa Rodriguez spoke to Administrator David Berry via telephone and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently two (2), Westside Regional Center Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

The following 12 Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a single-story-family home located in a residential neighborhood. Ms. Rodriquez and LPA Bunker toured the facility which consisted of the following: Living room, dining area, kitchen, 4 bedrooms, 2 bathrooms, family room, laundry area, shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit.

Due to time, constraint LPA Bunker was unable to complete the visit. There were no deficiencies cited.
Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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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