198320193-6-18-2021-11-AS-EBRN-C44QH5-20210618121035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320193
Report Date: 06/18/2021
Date Signed: 06/18/2021 12:11:41 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
MONTEREY PARK, CA 91754

FACILITY NAME:	HOME SWEET HOME - HOME CARE FACILITY LLC		FACILITY NUMBER:	198320193
ADMINISTRATOR:	WILLIAMS, TRACY		FACILITY TYPE:	735
ADDRESS:	1524 W 97TH STREET		TELEPHONE:	(323) 531-2043
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY:	4	CENSUS: 0	DATE:	06/18/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Tracy WIlliams, Applicant		TIME COMPLETED:	12:25 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 this date, LPA Brown conducted a pre-licensing investigation at this facility with Applicant Tracy Williams. An application was submitted to Community Care Licensing Department (CCLD) and received on 3/2/2021 for an initial application to serve individuals for ages 18 through 59 years. The requested capacity is for four (4) residents. Structure: The facility consists of 4 resident bedrooms, 3 resident bathrooms, dining area, kitchen, living room, laundry area, office area and a patio area in the backyard. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. The facility has one bedroom that has a bathroom inside, along with an exit door that leads to the backyard. Resident bathrooms were checked. Toilets and water faucets worked properly; shower was free of mold/mildew. Common areas were clean and clear of hazards; doorways were free of obstruction. Linens & Hygiene Supplies: Resident bath towels, toiletries and personal hygiene supplies were adequately stocked in the client bedrooms. Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Ample supply of linen is stored at the facility. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in the office area. Facility has a land line telephone. The facility has 2 fully charged fire extinguishers. Food Service: Dishes, cups, and flatware are stored in the facility’s kitchen. Ample food supply is stored in the kitchen and consists of the following: 7-day non-perishables. Smoke Detectors/Carbon Monoxide(s): Facility has inter-connected smoke detectors and a carbon monoxide detector. Appliances: Stove burners, gas oven, microwave, and washer/dryer are in working condition. Toxins: Cleaning supplies and toxins are stored in locked cabinet under the kitchen sink. Medication, First-Aid Kit & Book: Designated centrally stored medication will be stored inside of a locked cabinet in the kitchen. First-aid kit has sufficient bandages, one (1) tweezer, one (1) thermometer, one (1) First Aid Manual, and one (1) pair of scissors. Clients & Staff Files: Designated area for files is a file cabinet in the office area. Applicant will not handle cash resources of clients.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HOME SWEET HOME - HOME CARE FACILITY LLC	FACILITY NUMBER: 198320193
	VISIT DATE: 06/18/2021

NARRATIVE

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Reading Material, Games, Equipment & Materials: The facility has books, board games and other recreational materials for the client's use, commensurate with the plan of operation. Pools/Jacuzzi & Pets: The facility does not have any bodies of water or pets. Fire Clearance: Fire clearance was approved on 6/3/2021.

Component III:

Applicant Tracy Williams has successfully read and reviewed the Component III Orientation.

When the applicant was asked if she had a general understanding of Title 22 she responded in the affirmative.

An exit interview was conducted with Applicant Tracy Williams, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC809 (FAS) - (06/04)

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