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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191670439
Report Date: 04/11/2022
Date Signed: 04/11/2022 04:46:53 PM

Document Has Been Signed on 04/11/2022 04:46 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
MONTERY PARK, CA 91754
FACILITY NAME:CHANDLER FAMILY HOMEFACILITY NUMBER:
191670439
ADMINISTRATOR:JONES, SHIRLEY A.FACILITY TYPE:
735
ADDRESS:9116 CRENSHAW BLVD.TELEPHONE:
(323) 777-2131
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY: 10CENSUS: 10DATE:
04/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Shirley JonesTIME COMPLETED:
04:30 PM
NARRATIVE
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On 04/11/2022 Licensing Program Analyst (LPA) Stephanie Cifuentesl conducted a Case Management- Other to the above facility and met with Administrator Shirley Jones.

During annual inspection on 4/11/2022 LPA Cifuentes noted that water in facility bathrooms measures 120.8F
Deficiencies cited under California Code of regulation title 22 Division 6 Chapter.

Please see 809 D for citations.

An exit interview was conducted. Plans of corrections were developed.

A copy of this report and Appeals Rights were provided to Shirley Jones, Licensee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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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Document Has Been Signed on 04/11/2022 04:46 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 04/11/2022 at 04:20 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
MONTERY PARK, CA 91754

FACILITY NAME: CHANDLER FAMILY HOME
FACILITY NUMBER: 191670439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2022
Section Cited
CCR
80087(e)(1)

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Furniture, Fixtures, Equipment, and Supplies
Hot water temperature controls shall be maintained to automatically regulate temperature... of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by:
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Licensee will monitor hot water for 24 hours and submit plan of correction to LPA via fax by POC due date.
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During annual inspection LPA observed thatthat hot water temperature in facility bathrorms was 120.8F, which poses an immediate health risk to residents 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022


LIC809 (FAS) - (06/04)
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