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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201918
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:27:50 PM

Document Has Been Signed on 07/21/2022 02:27 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:CHALLENGE ONE ARFFACILITY NUMBER:
198201918
ADMINISTRATOR:GIL TEELFACILITY TYPE:
735
ADDRESS:500 W. HILLSDALE STREETTELEPHONE:
(323) 815-9881
CITY:INGLEWOODSTATE: CAZIP CODE:
90302
CAPACITY: 4CENSUS: 4DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Erika Scales, House ManagerTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Erika Scales, and later met with Kuki Phillips, Administrator and the purpose of today’s visit was explained.

There are currently (4) West-Side Regional Center consumers in placement. All (4) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, family room/office, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and a detached garage.

LPA and Erika & Esther (care givers) toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1-4 (A, B, C, & D) are occupied by clients and contain the mandated furnisher. Room A has a hole in the wall. The (2) bathrooms are clean and operational. Bathroom #2 tub is stained looks dirty:needs re-glazing. Smoke detectors and carbon monoxide detector comply and are operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 staff file is current, 1 resident file, medications, and P&I money is current and complete. The water temperature is at 114.3 Degrees Fahrenheit. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, (1) fire extinguishers is fully charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CHALLENGE ONE ARF
FACILITY NUMBER: 198201918
VISIT DATE: 07/21/2022
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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in all bathrooms, and additional sanitation supplies stored in a shed in the back yard. LPA observed staff and clients wearing masks, clients room will be isolation rooms, if needed. Required postings throughout the facility. Trash can with lids, Carts with PPE’s, and Fit testing done for staff. The facility has an approved Mitigation plan. Visitors are logged and temperatures checked. The client’s temperatures are checked and logged 2x a day.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Erika Scales, and a hard copy and Appeal Rights provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2022 02:27 PM - It Cannot Be Edited


Created By: Ana Soto On 07/21/2022 at 11:19 AM
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
MONTEREY PARK, CA 91754

FACILITY NAME: CHALLENGE ONE ARF
FACILITY NUMBER: 198201918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
POC Due Date: 08/08/2022
Plan of Correction
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Facility will ahve maintenance personnel fix hole in wall and re-glaze bathtub. Will send LPA picture of repairs by and/or on POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
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