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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601267
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:17:00 PM

Document Has Been Signed on 09/01/2022 02:17 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 COMMUNITY LIVING RESIDENTIAL FACILITYFACILITY NUMBER:
191601267
ADMINISTRATOR:DAVID BERRYFACILITY TYPE:
735
ADDRESS:14708 FRAILEY AVETELEPHONE:
(310) 637-4604
CITY:RANCHO DOMINGUEZSTATE: CAZIP CODE:
90221
CAPACITY: 6CENSUS: 5DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Martha MiramontesTIME COMPLETED:
02:30 PM
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On 09/01/22, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Annual Required visit with a primary focus on infection control measures. Upon arrival at the facility, LPA met with facility representative, Martha Miramontes and conducted a risk assessment on the facility front porch. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct the inspection, and the purpose of the visit was explained. LPA was properly screened for Covid-19 symptoms and temperature was checked and logged in the visitor’s book.

The facility is licensed to serve clients age range 18 through 59, ambulatory only. There are currently 5 South Central Los Angeles Regional Center clients in placement. All 5 clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: living room, kitchen, dining area, four (4) bedrooms, two (2) bathrooms, enclosed patio area, patio with chairs and a detached two-car garage.
During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is in the front living room. LPA observed staff and residents wearing a face covering. LPA also observed covid postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: C-H COMMUNITY LIVING RESIDENTIAL FACILITY
FACILITY NUMBER: 191601267
VISIT DATE: 09/01/2022
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LPA Scott and Miramontes toured the facility and there are no bodies of water or firearm/ammunition on the premises. All passageways inside and outside of the facility were clear of obstructions. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 101.7 F. A comfortable temperature is maintained in the facility. Several client/staff files were checked for accuracy and found no inaccuracies.

LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which are stored properly. Fire extinguisher was charged, smoke and Carbon Monoxide detectors were operable. All mandated signage were posted.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1), there were no deficiencies cited at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to facility representative Martha Miramontes.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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