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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320191
Report Date: 12/18/2023
Date Signed: 12/18/2023 02:48:00 PM

Document Has Been Signed on 12/18/2023 02:48 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:FORT FAITH RCFEFACILITY NUMBER:
198320191
ADMINISTRATOR:FORT, NISHAFACILITY TYPE:
740
ADDRESS:710 LACONIA PLTELEPHONE:
(213) 362-8837
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 4CENSUS: 2DATE:
12/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marcia BaileyTIME COMPLETED:
03:00 PM
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On 12/18/23 1:50 PM Licensing Program Analyst (LPA), Regina Cloyd, conducted an unannounced visit to the facility listed above for the purpose of a plan of correction follow up visit and met with Marcia. LPA spoke with Administrator Nisha Forte over he phone. There was no residents here during the visit.

On 11/27/23, LPA conducted an annual inspection at the facility and did not observe health screenings with TB results for two staff members and a medical assessment for resident #2. A deficiency was issued and the plan of correction was developed with the licensee. The licensee advised that she will email the documents by 12/12/23; though, she may have issues sending the medical assessment. As of 12/18/23, the medical assessment was not received.

A violation for not resolving the deficiency warrants an immediate civil penalty of $600 and is hereby assessed, see LIC421FC. Note, a $100 per day violation will continue to be accrued until the licensee corrects the deficiency(s).

An exit interview was conducted and a copy of this report and the LIC421FC was left with Marcia.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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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