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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320100
Report Date: 08/08/2023
Date Signed: 08/08/2023 10:17:55 AM

Document Has Been Signed on 08/08/2023 10:17 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:JACOBS ARFFACILITY NUMBER:
198320100
ADMINISTRATOR:JACOBS, ASHLEYFACILITY TYPE:
735
ADDRESS:13704 ARDATH AVENUETELEPHONE:
(850) 621-2309
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 4CENSUS: 1DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Ashley JacobsTIME COMPLETED:
10:30 AM
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On 8/08/2023, 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 Administrator Ashley Jacobs explained the purpose of today’s visit. The facility is licensed for four (4) ambulatory clients between the ages of 18-59. Todays census is one (1).

The facility is a single-story home located in a residential neighborhood. The facility consists of the following: three (3) resident bedrooms, one (1) staff bedroom, two (2) bathroom, dining area, kitchen, living room and shaded patio area in the backyard.

LPA walked through all three (3) rooms. Bedrooms 1-3 are designated for the resident’s individual use. The bedroom 4 is designated for staff. All bedrooms contained a bed, dresser, nightstand, chair, ample lighting and closet space.

LPA walked through the kitchen and all appliances were in good working order. Knives were locked and stored in a drawer in the kitchen and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured degrees Fahrenheit.

All bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly. The walk-in shower was free of mildew and mold and had shower chairs available. LPA walked through the laundry room, all cleaning products were locked in a cabinet and inaccessible to residents.

LPA walked through all common areas. In the living room, family room, dining room and activity room there is ample seating and space for all residents. LPA observed games and activities for residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, family room and living room have working smoke detectors. Carbon monoxide detector was functional. There is a fully charged fire extinguisher in the dining room.

Con'd 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: JACOBS ARF
FACILITY NUMBER: 198320100
VISIT DATE: 08/08/2023
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LPA walked the outside of the facility. In the back yard there is a table, chairs and umbrella for residents and visitors use. All walkways were clear of debris, obstructions and hazards. LPA did not observe any bodies of water.


No deficiencies were cited during this inspection visit.


An exit interview was conducted and a copy of this report was provided to Denell Jacobs
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC809 (FAS) - (06/04)
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