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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320057
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:51:52 PM

Document Has Been Signed on 06/20/2024 02:51 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HOLMES SWEET HOMEFACILITY NUMBER:
198320057
ADMINISTRATOR/
DIRECTOR:
WILLARD III, JESSFACILITY TYPE:
735
ADDRESS:1432 W. 89TH STREETTELEPHONE:
(323) 696-9794
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 0DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:59 PM
MET WITH:Willard III JessTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 06/20/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced required 1- year visit using the new CARE Inspection Tool. LPA Richard met Licensee Jess Willard and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently zero (0) clients in placement. The facility is vendored with South Central Los Angeles Regional Center (SCLRC). The facility's annual fees are current.


The facility is a single-family home located in a residential neighborhood. Licensee Jess Willard and LPA Richard toured the facility which consisted of the following: Living area, kitchen, dining room, 3 bedrooms, 1 bathroom, laundry area, locked medication cabinet in the hallway, a locked supply closet, shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit.

See continued LIC809-C on page 2
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HOLMES SWEET HOME
FACILITY NUMBER: 198320057
VISIT DATE: 06/20/2024
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Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the furniture mandated, Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications and file folders are in a locked cabinet. Common areas were observed for the ability to safely serve the needs of the residents, including cleanliness, and clearness of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 118.1 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working, resident. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. The administrator Certificate expired on 03/05/2025.

There were no deficiencies cited. Exit interview conducted. A copy of the report was provided to Licensee Jess Willard.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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