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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191640255
Report Date: 04/15/2021
Date Signed: 01/31/2022 02:04:17 PM

Document Has Been Signed on 01/31/2022 02:04 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:FRANK'S ADULT RESIDENTIAL HOMEFACILITY NUMBER:
191640255
ADMINISTRATOR:EDWARD GOODSONFACILITY TYPE:
735
ADDRESS:1911 W. 137TH STREETTELEPHONE:
(310) 632-1213
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 16CENSUS: 15DATE:
04/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Edward GoodsonTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Case Management - Deficiencies visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Edward Goodson, the facility licensee.

The purpose of this report is to document deficiencies observed during the course on complaint investigations with complaint numbers 11-AS-20210330150041 and 11-AS-20210408145615.

On 04/08/2021 LPA conducted a regional office record review LPA observed that the licensees administrator certificate and staff (S1) Terren Adams administrator certificate were expired. On 04/08/2021 LPA interviewed the licensee and the licensee confirmed that his administrators certificate has been expired since 2018. On 04/12/2021 the licensee submitted copies of the licensee and S1's expired administrator certificates.

On 04/15/2021 LPA conducted record reviews and did not observe staff (S3) Annette Evans' criminal record clearance was not transferred to Frank's Adult Residential. On 04/15/2021 S3 stated that she started "I started working 3 weeks ago."

A telephonic exit interview was conducted with Edward Goodson, appeals rights and a copy of this report was provided via email for review and signature.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2021
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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Document Has Been Signed on 01/31/2022 02:04 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 04/15/2021 at 02:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FRANK'S ADULT RESIDENTIAL HOME
FACILITY NUMBER: 191640255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2021
Section Cited
CCR
85064(b)

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85064(b) Adminstrator Qualifications and Duties. All adult residential facilities shall have a certified administrator.

This requirement was not met as evidenced by:
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The licensee shall review title 22 Regulation 85064(b) Administrator Qualification and create a plan of correction indicating the steps to be taken to obtain compliance and submit the plan to LPA via email on or before the POC due date.
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Based on record reviews and interviews conducted the licensee failed to ensure that the facility has a certified administrator. Which poses apotential health and safety rick to clients in care.
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Type B
04/16/2021
Section Cited
CCR80019(e)

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 80019(f) or
This requirement was not met as evidenced by:
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The licensee will submit request for transfer of S3's criminal record clearance at the regional office, proof of correction will be submitted to LPA via email by POC due date.
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Based on record reviews and interviews the licensee failed to ensure that individuals request a transfer of criminal record clearance prior to working at facility. S3's criminal record clearance was not transferred to facility, which poses a potential health and safety risk to client in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2021


LIC809 (FAS) - (06/04)
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