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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320065
Report Date: 06/14/2024
Date Signed: 06/18/2024 03:16:11 PM

Document Has Been Signed on 06/18/2024 03:16 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:CLEMENT CARE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198320065
ADMINISTRATOR/
DIRECTOR:		NTUNG, JOSEPH & HELENFACILITY TYPE:
735
ADDRESS:613 WEST 98TH STREETTELEPHONE:
(310) 766-2760
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 4CENSUS: 3DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Elizabeth Lemwi staff/ Joseph Ntung Admin LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On 06/14/2024 at 9:30am Licensing Program Analyst (LPA) Troy Watson conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Joseph Ntung and the purpose of today’s visit was explained. The facility is licensed to operate for (4) developmentally disabled or Mentally Ill adults ages 18 - 59. Currently, the home has (3) clients.

The facility is a single-story structure located in a residential neighborhood. and consists of the following: four (4) client bedrooms, two (3) common bathrooms, a living area, dining area, kitchen, and outside patio area and a front porch area with chairs for the clients enclosed by a fence.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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: CLEMENT CARE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320065
VISIT DATE: 06/14/2024
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LPA Troy Watson observed the facility clean, sanitary, and appropriately furnished at the time of the visit. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. (2) Carbon monoxide and (7) Smoke detectors were observed and operational. One fire extinguisher was fully charged, toxins and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, and medicine checked and accounted for. The first aid kit was checked and fully stocked. Fire and disaster drills were conducted last month.

LPA conducted a records review of (3) client records, (2) staff records and (3) Client Medication Administration Records (MAR) and found no discrepancies. LPA reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit.

An exit interview was conducted, with the administrator Joseph Ntung and a copy of the Facility Evaluation Report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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