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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191840977
Report Date: 11/16/2022
Date Signed: 11/16/2022 05:00:01 PM

Document Has Been Signed on 11/16/2022 05:00 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:UNDERWOOD GUEST HOMEFACILITY NUMBER:
191840977
ADMINISTRATOR:PIGGEE, MARIONFACILITY TYPE:
735
ADDRESS:1274 3RD AVENUETELEPHONE:
(323) 937-2302
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 11CENSUS: 5DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Aretha CoulterTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by House Manager Aretha Coulter and the purpose of today’s visit was explained.

There are currently (5) clients in the facility. The facility is licensed to serve (11) developmentally/ mentally disabled adults ages 18-59 years old, all ambulatory. Facility is operating within the approved capacity.

LPA and House Manager Aretha Coulter toured the entire facility inside and out. The facility is a two story structure located in a residential neighborhood. Facility consists of the following: There are a total of 6 bedrooms throughout the house. The first floor consists of a living room, staff office, family room, kitchen, dining room, and 2 bedrooms. One bedroom downstairs is for the live-in staff and the other bedroom is vacant. The second floor has 4 bedrooms, 2 and T.V. room. The hot water temperature is measured 120F. The attic upstairs and basement downstairs are used as storage. Additional refrigerator is located in the basement. Facility has a patio covered seating area Bathrooms are clean and operational. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. The facility was at a comfortable temperature. All client rooms that were inspected had the required furniture for comfort and safety such as bed frames, dressers, lamps and chairs and all had sufficient lighting. Clients beds have the required linen and the linen was in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Ample supply of perishable and nonperishable food. Linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: UNDERWOOD GUEST HOME
FACILITY NUMBER: 191840977
VISIT DATE: 11/16/2022
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The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms bathrooms and hallways.
  • Unoccupied facility rooms are able to used as designated isolation rooms if a COVID-19 positive case should arise.
  • 30 day supply of medication for clients
  • Facility has an adequate amount of PPE and facility has enough PPE for 6 months +.
  • Clients were socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Hand Sanitizer: Available throughout the facility for client use.
  • The clients temperature's are checked and logged three times a day in the AM/ Midday and PM.
  • Staff and clients are tested weekly for COVID-19.
  • Staff temperatures are checked upon getting to the facility and then again upon leaving.


Exit interview conducted, a copy of this report was provided to House Manager Aretha Coulter.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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