198320100-8-14-2024-11-AS-FSHY-D83U58-20240812151618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320100
Report Date: 08/12/2024
Date Signed: 08/14/2024 08:30:17 AM

Document Has Been Signed on 08/14/2024 08:30 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	JACOBS ARF		FACILITY NUMBER:	198320100
ADMINISTRATOR/ DIRECTOR:	JACOBS, ASHLEY		FACILITY TYPE:	735
ADDRESS:	13704 ARDATH AVENUE		TELEPHONE:	(850) 621-2309
CITY:	GARDENA	STATE: CA	ZIP CODE:	90249
CAPACITY: 4		CENSUS: 1	DATE:	08/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:28 PM
MET WITH:	Ashley Jacobs, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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On 08/12/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Ashley Jacobs and explained the purpose of today’s visit. The facility is licensed to serve developmentally disabled residents ages 18 to 59. This facility is cleared for four (4) ambulatory residents. During the time of visit the one (1) resident was not present, they were at their day program. Resident arrived at 2:50pm.

LPA Shirley reviewed the resident file and found that it contained the required documents. LPA reviewed three (3) staff files and found they contained the required documents, training, and certification. LPA reviewed residents MAR and medications. LPA reviewed the surety bond.

LPA Shirley and Ashley toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) client bedrooms, with one (1) staff room, (1) bathroom, and with one (1) bathroom for the staff, a living room, kitchen, dining area, closet in which washer and dryer are stored, patio, garage used for storage.

All bedrooms were toured. The fourth bedroom is occupied by the resident and contains the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms and hallway.

LPA Shirley and Ashley toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored in a cabinet in the kitchen. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 113.1 degrees Fahrenheit.

Con'd 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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: JACOBS ARF	FACILITY NUMBER: 198320100
	VISIT DATE: 08/12/2024

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The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Ashley walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen and in a box. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

There were no deficiencies observed or issued.

An exit interview was conducted, and a copy of this report was provided to Administrator, Ashley Jacobs.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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