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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601267
Report Date: 10/09/2023
Date Signed: 10/09/2023 03:56:23 PM

Document Has Been Signed on 10/09/2023 03:56 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 ASC, 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:
3106374604
CITY:RANCHO DOMINGUEZSTATE: CAZIP CODE:
90221
CAPACITY: 6CENSUS: 5DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Rebekah JeffersonTIME COMPLETED:
04:20 PM
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 ON 10/09/23, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual Required visit using the new Care Inspection Tool. Upon arrival at the facility, LPA met with facility representative, Rebekah Jefferson and explained the purpose of today's visit.

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 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 also observed COVID postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: C-H COMMUNITY LIVING RESIDENTIAL FACILITY
FACILITY NUMBER: 191601267
VISIT DATE: 10/09/2023
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LPA Richard and staff Jefferson 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 hot water temperature measured 111. 4F degrees. A comfortable temperature is maintained in the facility. Several client/staff files were checked.

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 inspection control posters were posted and available.

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 report was provided to the staff Rebekah Jefferson.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC809 (FAS) - (06/04)
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