198320161-1-25-2021-11-AS-SCIS-BXM42N-20210125174324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320161
Report Date: 01/25/2021
Date Signed: 01/25/2021 05:43:38 PM

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
MONTERY PARK, CA 91754

FACILITY NAME:	DENVER RESIDENTIAL FACILITY, INC DBA DENVER RESID		FACILITY NUMBER:	198320161
ADMINISTRATOR:	ALLEN, LYNN TI		FACILITY TYPE:	735
ADDRESS:	14410 S DENVER AVE		TELEPHONE:	(810) 756-3839
CITY:	GARDENA	STATE: CA	ZIP CODE:	90248
CAPACITY:	4	CENSUS: 0	DATE:	01/25/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Jeanette Kidd-Licensee		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/25/2021 Licensing Program Analyst (LPA), Stephanie Cifuentes conducted an announced visit to the above facility for purpose of a pre-licensing evaluation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s inspection was conducted via Facetime and Zoom with Jeanette Kidd, the facility licensee. During the inspection LPA toured the inside and outside of the facility. An application was submitted to CCLD on 10/26/2020, for an initial application for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18 to 59 years. The requested capacity is for 4 clients, 4 non-ambulatory, no ambulatory. Facility has a fire clearance for 4 non-ambulatory clients only. Structure: Facility is a 4 client-bedroom, 1 office, 2 bathroom, one-story house. The client bedrooms are spacious and easily accommodate the client's furnishings. There is a back yard with a shaded patio area and chairs. Shaded area has sufficient tables and chairs for clients. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: All four client bedrooms have a chair, night stands, over-head lighting, dressers and closets. The closet and drawers comply with the requirement of 8 cubic feet of space. Office: Facility has an office with a desk, chairs and cabinets. Bathrooms: Facility has 2 bathrooms. Both bathrooms where observed to have a working toilet, wash basin and showers/bathtubs. Continued on 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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
MONTERY PARK, CA 91754

FACILITY NAME: DENVER RESIDENTIAL FACILITY, INC DBA DENVER RESID	FACILITY NUMBER: 198320161
	VISIT DATE: 01/25/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillow cases, hand towels, bath towels and wash cloths where observed stored in the hallway cupboard and in some of the residents closets. Facility provides hygiene supplies to clients and LPA observed an adequate supply of tooth paste, shampoo, conditioner, body wash and deodorant.

Emergency Phone Numbers, Exit Plan & Menu: The telephone, which is a land line, was called by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on the wall between of the dining room. 2 fully charged fire extinguisher where found, one next to the kitchen and another in the hallways where two resident bedrooms and the office are located.

Food Service: Dishes, cups and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer in kitchen. Food supply was adequately stored in kitchen refrigerator, cabinets and pantry and consists of the following: a variety of fresh and canned fruit, vegetables and meats.

Smoke Detectors: 7 dual smoke and carbon monoxide detectors are hardwired and interconnected. All were operational.

Appliances: Stove burners, oven, microwave, dish washer, washer, and dryer working. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.

Toxins: Locked/stored in cabinet under sink.

Medications, First-Aid Kit & Book: Area for medication storage is in a cabinet in dining area. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to clients.

Clients & Staff Files: Records of staff and clients are to be stored in cabinets in staff room.

Continued on 809-C.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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
MONTERY PARK, CA 91754

FACILITY NAME: DENVER RESIDENTIAL FACILITY, INC DBA DENVER RESID	FACILITY NUMBER: 198320161
	VISIT DATE: 01/25/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use as well as an activity calendar.

Pool/Jacuzzi & Pets: LPA's did not observe any pet or bodies of water at the facility.

Fire clearance: Fire Clearance was approved on 12/29/2020 for 4 non-ambulatory clients. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gate and front exits.

Component III: Conducted at the Pre-Licensing visit, on 1/25/2021 at Denver Residential Facility, Inc DBA Denver Resid, information provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection no items were observed which do not comply with applicable laws and regulations; no items require a follow up inspection for verification of correction

Pre-Licensing is complete and this facility has no deficiencies.

An exit interview was conducted, and a copy of this report has been furnished to the applicant via email for signature.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3