<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200416
Report Date: 12/05/2022
Date Signed: 12/05/2022 01:26:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/05/2022 01:26 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:THEL'S BOARD AND CAREFACILITY NUMBER:
198200416
ADMINISTRATOR:WILLIAMS, THELMA E.FACILITY TYPE:
740
ADDRESS:969 W. VERNON AVETELEPHONE:
(323) 231-4544
CITY:LOS ANGELESSTATE: CAZIP CODE:
90037
CAPACITY:14CENSUS: 0DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Vicky BuieTIME COMPLETED:
01:35 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 12/5/22, Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced annual required visit. LPA met with Vickie Buie and explain the purpose of today’s visit.

The home consists of a two (2)-story structure located in a residential/business neighborhood. The residents' rooms are located upstairs. It consists of the following: seven (7) client’s bedroom, living room, dining room, kitchen, and an office. Upstairs there are 1 and 1/2 resident bathrooms. Downstairs there is a staff/visitor bathroom and administrator bedroom.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds, furnisher, lighting and no clients personal belongings were observed. LPA was informed there were no clients at the home. Client C#1 is back with family after being discharged from hospital. Clients (C#2- C#5) were relocated to another facility on 10/1/2022. See LIC 812. LPA observe a fire extinguisher fully changed on the second floor.

During the visit, LPA was not able to focus on Infection Control measures using the CARE Inspection Tool because there was no back up administrator at the home.

Administrator and Licensee Thelma E. Williams was not present during the visit. Vickie informed LPA home is closed, property is on the market to be sold and Community Care License will be closed as soon as possible. Please see LIC812.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to Vickie Buie.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1