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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320191
Report Date: 07/31/2024
Date Signed: 07/31/2024 09:31:32 AM

Document Has Been Signed on 07/31/2024 09:31 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:FORT FAITH RCFEFACILITY NUMBER:
198320191
ADMINISTRATOR/
DIRECTOR:		FORT, NISHAFACILITY TYPE:
740
ADDRESS:710 LACONIA PLTELEPHONE:
(213) 362-8837
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 4CENSUS: 2DATE:
07/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Marcia Bailey - Care Giver TIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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On 07/30/2024 at 12:44 PM Licensing Program Analyst (LPA) Troy Watson conducted an unannounced annual required visit. (LPA) met with the Marcia Bailey for (2) developmentally disabled or mentally ill adults ages 59 and up. Currently the home has (2) clients.The facility is a one story structure located in a residential neighborhood and consists of the following: (3) client bedrooms, two (2) common bathrooms (1) living room area (1) dining area, (1) kitchen, an outside patio area and a front porch area. LPA Troy Watson toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser chairs and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. The bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly.The bathtub was free of mold/mildew. There is adequate lighting, and sufficient toiletries are accessible to clients. The water temperature properly measured between 116 F and 117.2 F in the bathrooms and in the Kitchen.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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: FORT FAITH RCFE
FACILITY NUMBER: 198320191
VISIT DATE: 07/31/2024
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LPA Troy Watson observed the facility clean, sanitary, and appropriately furnished at the time of the visit. The kitchen, and refrigerator was fully stocked with food. The administrator has (4) smoke detectors/carbon monoxide detectors that have been tested and found operational. Toxins and knives were locked and inaccessible to clients. Medications were inspected and accounted for at the time of inspection. The first aid kit was checked and fully stocked with a certified manual. LPA reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. Staff records and P&I were presently available for immediate review and inspection.

An exit interview was conducted, and a copy of this report was provided

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
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