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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320180
Report Date: 04/12/2023
Date Signed: 04/12/2023 04:56:56 PM

Document Has Been Signed on 04/12/2023 04:56 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:2NTHESAME HOMEFACILITY NUMBER:
198320180
ADMINISTRATOR:WILSON, DARLENEFACILITY TYPE:
735
ADDRESS:622 CYPRESS STREETTELEPHONE:
(310) 714-4006
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 3CENSUS: 0DATE:
04/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:WILSON MARLENETIME COMPLETED:
05:15 PM
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On 04/12/23, Licensing Program Analysts (LPA) Antonine Richard conducted an unannounced Annual required visit using the new Care Inspection Tool. LPA was met with Licensee Marlene Wilson and the purpose of today’s visit was explained. The facility is licensed to serve 3 developmentally disabled clients (age 18-59). All non-ambulatory

There are currently (0) clients and no staff. Administrator is waiting for South Central vendorization approval. The facility is a two story structure located in a residential neighborhood. It consists of the following: 3 bedrooms and 2 bathrooms, family/dining room, kitchen, living room, indoor and outdoor activity with shaded area, Laundry room area located inside in the garage.

LPA and Licensee toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. All beds and bedding were in good condition and adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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 hot water temperatures measured in the bathroom at 111.3F degrees Fahrenheit. A comfortable temperature is maintained throughout the facility.

LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps objects were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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: 2NTHESAME HOME
FACILITY NUMBER: 198320180
VISIT DATE: 04/12/2023
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff sanitizing stations (Located in common areas and restrooms). LPA observed, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-days supply of Personal Protective Equipment (PPE).

LPA advised Licensee to continuously monitor the Centers for Disease Control (CDC) website and Community Care Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

An exit interview was held. A copy of the report was provided to Licensee Marlene Wilson.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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