197803050-11-7-2023-11-AS-JCAN-CX8T7X-20231103142927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803050
Report Date: 11/03/2023
Date Signed: 11/07/2023 08:27:32 AM

Document Has Been Signed on 11/07/2023 08:27 AM - 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:	AGAPE CHRISTIAN-CLARK HOUSE		FACILITY NUMBER:	197803050
ADMINISTRATOR:	LATASHIA HAMMOND		FACILITY TYPE:	735
ADDRESS:	3454 CLARK AVENUE		TELEPHONE:	(562) 421-4690
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY: 5		CENSUS: 4	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	ADMINISTRATOR LATASHA HAMMOND		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/03/2023, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual required visit to Facility Agape Christian Clark House with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Calderon met with the Administrator Latashia Hammond. LPA Calderon explained the purpose of today’s visit. The facility is licensed to operate for (5) ambulatory adults ages 18 through 59 years of age with developmental disabilities. There are currently (4) clients 18 to 59 years of age with developmental disabilities living at the facility. The clients are Harbor Regional Center consumers. The facility is a single-story structure located in a residential neighborhood. It consists of the following:(4) client's rooms, (2) common bathrooms, a living area, dining area, family room, kitchen, and outside patio area. LPA Calderon explained to Administrator Latashia Hammond, the purpose of the one-year (1) Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: (4) resident service records, (4) resident medication records, (3) staff records. LPA Calderon interviewed (4) residents and (3) staff members for visit. LPA Calderon inspected the inside facility and outside grounds to include all common areas. The facilities’ last fire drill was conducted on 10/30/2023. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day (2) supply of perishable and seven-day (7) supply of non-perishable foods are present in the facility. Emergency Water seven-day (7) supply is found in the garage.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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: AGAPE CHRISTIAN-CLARK HOUSE	FACILITY NUMBER: 197803050
	VISIT DATE: 11/03/2023

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 102 degrees Fahrenheit. Bathroom #2 hot water temperature properly measured at 105 degrees Fahrenheit. Kitchen hot water temperature properly measured at 103 degrees Fahrenheit. Facility (2) carbon Monoxide and (7) Smoke Detectors hard wired and were tested and are working properly. The facility has two (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit (1) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. LPA Calderon noted the Administrator Latashia L Hammond Certification #6041462735 expiration date of 11/13/2024 was valid at time of visit. The facility does handle resident's money/cash resources and Surety bond is needed. Nationwide Surety Bond #7900650147 for $2000.00 dollars expires on 01/06/2026. Commercial General Liability Policy #PAC3448300 policy period from 09/29/2023 to 09/29/2024 underwritten by Great American Assurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Latashia Hammond who will email full copy of insurance contact which shows all coverages to LPA Calderon no later than 11/20/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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: AGAPE CHRISTIAN-CLARK HOUSE	FACILITY NUMBER: 197803050
	VISIT DATE: 11/03/2023

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident vaccination records, test results, and daily temperature screening. The facility has an approved CCLD Mitigation Plan.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Latashia Hammond.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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