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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600461
Report Date: 03/18/2022
Date Signed: 03/18/2022 05:04:19 PM

Document Has Been Signed on 03/18/2022 05:04 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ADULT DEVELOPMENT CENTER - HERMOSA BEACHFACILITY NUMBER:
191600461
ADMINISTRATOR:LEUCI, MARYFACILITY TYPE:
775
ADDRESS:710 PIER AVE.TELEPHONE:
(310) 318-9343
CITY:HERMOSA BEACHSTATE: CAZIP CODE:
90254
CAPACITY: 52CENSUS: 0DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jenna Pierce, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Michael Murphy, Program Manager and Jenna Pierce, Administrator and the purpose of today’s visit was explained. The facility is a single-story structure located within the Hermosa Beach community center. They are licensed to serve developmentally disabled adults. 8 non-ambulatory and 44 ambulatory, a total of 52 clients.

There were currently no clients at the time of visit. Administrator stated they are planning to open the facility on 4/4/22. Facility consists of the following: main office, conference room, kitchen, 2 activity classroom, computer room, and 2 bathrooms are available for use by clients/staff that are part of the community center. The facility program is through Harbor Regional clients. LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. The tour consisted of the following: kitchen area, 2 activity classrooms, 2 bathrooms, computer room, gym and outside areas. The activity rooms had plenty of storage space and client cubbies. The kitchen area has 2 sinks and 2 refrigerators. Cleaning supplies were locked. All of the rooms that were inspected and clean. Activity rooms had 2 first aid kits and 2 fire extinguisher that were fully charge. Smoke detectors and carbon monoxide were working. Walls and floors were in good repair. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured in bathroom #1 107.5 F and 108.6 and bathroom #2 110 F and 110.4 F. A comfortable temperature is maintained in the facility.

LIC 809-C is on the next page.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ADULT DEVELOPMENT CENTER - HERMOSA BEACH
FACILITY NUMBER: 191600461
VISIT DATE: 03/18/2022
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LPA observed the facility’s wall and floors to be clean and in good repair during the time of visit. Storage areas were stocked with PPE supplies such as N95’s, gowns, gloves, hand sanities and cleaning supplies. All cleaning/toxins supplies were locked in the cabinet and sharps were inaccessible to clients.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff were wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the sign report was provided to Jenna Pierce, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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