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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320002
Report Date: 05/17/2022
Date Signed: 05/18/2022 02:40:00 PM

Document Has Been Signed on 05/18/2022 02:40 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:HOME SWEET HOME LAFACILITY NUMBER:
198320002
ADMINISTRATOR:WILLIAMS, TRACYFACILITY TYPE:
735
ADDRESS:1218 W 106TH STTELEPHONE:
(323) 696-9331
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 6CENSUS: 2DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:WILLIAMS, TRACYTIME COMPLETED:
11:48 AM
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On 5/17/2022, Licensing Program Analyst (LPA) Ngozi Nwaokoro conducted an unannounced inspection visit to this facility. The purpose of today’s visit was to conduct a Required 1 Year Annual infection control inspection, with emphasis on infection control. LPA met with staff, Shanda Muckleroy, the Administrator Tracy Williams joined us later and explained the reason for the visit. The facility is licensed to serve 6 developmentally disabled clients (age 18-59). Currently, there are 3 client in placement. As a part of the inspection, LPA inspected the entire facility, reviewed clients record, medication mar and staff records.

LPA and Tracy Williams toured the entire facility, which includes 4 client bedrooms, 2 bathrooms, living room, dining room and kitchen. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. Hot water temperature properly measured at 105.4 degrees. LPA observed the facility to be clean and appropriately furnished. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients.

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors/carbon monoxide detector were working properly, fire extinguishers were fully charged and operational, toxins and knifes were locked and inaccessible to clients. Outside grounds were toured and no bodies of water were observed.

Exits/ Walkways around the home were free of debris and hazards. No deficiencies cited, an exit Interview conducted, and a copy of the report was given to the Administrator, Tracy Williams.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Ngozi Nwaokoro
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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