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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320007
Report Date: 09/09/2021
Date Signed: 10/07/2021 08:48:50 AM

Document Has Been Signed on 10/07/2021 08:48 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:SUCCESSFUL PEOPLEFACILITY NUMBER:
198320007
ADMINISTRATOR:SNODDY, FRANCESFACILITY TYPE:
735
ADDRESS:1141 W 133RD STTELEPHONE:
(310) 819-8032
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY: 4CENSUS: 3DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Tracey Jewells-staffTIME COMPLETED:
01:20 PM
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On 9/9/2021, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with staff Tracey Jewells explained the purpose of today’s visit. The facility is licensed for four (4) ambulatory clients between the ages of 18-59.

The facility is a two-story home located in a residential neighborhood. The facility consists of the following: four (4) resident bedrooms, office, two (2) bathrooms, dining area, kitchen, living room and shaded patio area in the backyard.

LPA and staff toured the physical plant. There were no obstructions on the premises or small bodies of water. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. 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.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Seven (7) smoke detectors were observed to be hardwired and interconnected. Facility has three fire extinguishers, fully charged.

During the visit, LPA observed the facility infection control practices. LPA reviewed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted and available.

No deficiencies were cited during this inspection visit.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

An exit interview was conducted and a copy of this report was provided to Tracey Jewells.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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