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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607774
Report Date: 12/04/2024
Date Signed: 12/04/2024 01:33:09 PM

Document Has Been Signed on 12/04/2024 01:33 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:RICH RESIDENTIAL CARE, LLCFACILITY NUMBER:
197607774
ADMINISTRATOR/
DIRECTOR:
DEVIN HENDRICKFACILITY TYPE:
740
ADDRESS:9417 HAAS AVENUETELEPHONE:
(323) 757-7390
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 5TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:DEVIN HENDRICKTIME VISIT/
INSPECTION COMPLETED:
01:56 PM
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On 12/04/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual/Random using the new CARE Inspection Tool. LPA Richard met Licensee Gentry Richardson and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently four (4), South Central Los Angeles Regional Center (SCLARC) Residential Care For Elderly (RCFE) consumers in placement. The facility's annual fees are current.

The facility is a single-family home located in a residential neighborhood. Licensee Richardson and LPA Richard toured the facility which consisted of the following: Living room, kitchen, dining area, 4 bedrooms, one (1) bedroom designated as staff room/office, 2 bathrooms, laundry area in the garage, locked medication closet, a locked supply closet, shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit. Documents are posted as mandated. Bedrooms contain the furniture mandated, Bathrooms are clean and operational.

See continued LIC809-C on page 2
Eva M AlvarezTELEPHONE: (323) 629-7047
Antonine RichardTELEPHONE: (323) 516-4092
DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: RICH RESIDENTIAL CARE, LLC
FACILITY NUMBER: 197607774
VISIT DATE: 12/04/2024
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See continued LIC809-C on page 2

Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for the ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas were observed for the ability to safely serve the needs of the residents, including cleanliness, and clearness of any potential hazards to the residents.

The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance. The hot water temperature measured at 111.8F degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working, resident. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited. Exit interview conducted a copy of this report was provided to the Administrator.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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