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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320090
Report Date: 02/24/2022
Date Signed: 02/24/2022 04:53:14 PM

Document Has Been Signed on 02/24/2022 04:53 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:SOUTH BAY FAMILY HOME, LLCFACILITY NUMBER:
198320090
ADMINISTRATOR:CHAVEZ, KARENFACILITY TYPE:
735
ADDRESS:21821 ARCHIBALD AVE.TELEPHONE:
(310) 919-8272
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 1DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Karen ChavezTIME COMPLETED:
05:00 PM
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02/24/22, Licensing Program Analysts (LPA) Gail Johnson conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Johnson met with the Administrator Karen Chavez. LPA Johnson explained the purpose of today’s visit. The facility is licensed to operate and service four (4) ambulatory adults ages 18 through 59 two (2) of which may be non-ambulatory). Currently, one (1) client resides at this facility.

Facility Structure / Bedrooms (Client rooms)
The facility is a one-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms (one currently used by live in staff), two (2) client bedrooms) one (1) bathroom, living area, dining area, kitchen, outdoor area with table, chairs and umbrella. All rooms were inspected. Beds and bedding supplies were in good condition. Sufficient lighting was provided. Adequate storage for client personal belongings was observed.

Physical Plant
LPA Johns.on toured the physical plant. There were no bodies of water or obstructions on the premises. 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. The water temperature measured 110 degrees F.

Storage & Inaccessible Items
Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Two (2) fire extinguishers were fullty charged. Smoke detectors and carbon monoxide detectors were operable.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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: SOUTH BAY FAMILY HOME, LLC
FACILITY NUMBER: 198320090
VISIT DATE: 02/24/2022
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Infection Control
During the visit, LPA Johnson observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. Sanitizing stations in common areas and restrooms. LPA Johnson observed staff was wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file.


An exit interview was conducted with Karen Chavez. A copy of this report was printed and provided to Karen Chavez and signed by her staff designee Janet Moss.

End of report

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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