198320206-11-5-2021-11-AS-EDAT-C8H6W6-20211105210949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320206
Report Date: 11/05/2021
Date Signed: 11/05/2021 09:11:22 PM

Document Has Been Signed on 11/05/2021 09:11 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	234TH HOME		FACILITY NUMBER:	198320206
ADMINISTRATOR:	BOATNER, VERRETTA		FACILITY TYPE:	735
ADDRESS:	160 E. 234TH STREET		TELEPHONE:	(310) 872-3326
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 4		CENSUS: 0	DATE:	11/05/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	VERRETTA BOATNER		TIME COMPLETED:	11:06 AM

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 11/05/21, Licensing Program Analysts (LPAs) Ernand Dabuet and Ngozi Nwaokoro conducted an announced visit to this home. LPA was greeted by applicant Verretta Boatner and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 10/06/21. In the initial license application for a Residential Facility for Adults, ages ranging from 18-59 years old. The applicant requested for a capacity of four (4) individuals, of which two (2) ambulatory, two (2) non-ambulatory, and zero (0) bedridden. Structure: The home is a four (4) bedroom, two (2) bathroom, one-story home in a residential neighborhood. The home is a beige color structure that includes a living, dining, kitchen, and laundry area. The living area included sofas and a table. The kitchen has laminate countertops with a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. The patio is covered with a table and four (4) chairs and an umbrella for shade. Bedrooms Clients: The facility had four (4) bedrooms for clients. There are two (2) bedrooms for ambulatory clients and (2) two bedrooms for non-ambulatory clients. All rooms include (1) a full-size bed, one (1) chair, one (1) nightstand, one (1) table lamp. All bedrooms are equipped with ceiling fans with lights. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: 234TH HOME	FACILITY NUMBER: 198320206
	VISIT DATE: 11/05/2021

NARRATIVE

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Bedrooms Staff:
No bedrooms designated for staff.

Bathrooms:
The home has two (2) bathrooms. Bathroom #1 is accessible to bedrooms #1-#2 through a hallway. Bathroom #2 is for bedrooms #3 and #4. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in bedroom closets.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There are two (2) fire extinguishers located outside of bedrooms #1 and #4 mounted on the wall and fully charged. A telephone line is available in the office and living room area.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are in a locked cabinet under the sink. Food supply is stored in kitchen cabinets and consists of the can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all four (4) bedrooms and hallways. Carbon monoxide is combined with smoke detectors.

Toxins:
All toxins are locked/stored inside the hall closet.

Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: 234TH HOME	FACILITY NUMBER: 198320206
	VISIT DATE: 11/05/2021

NARRATIVE

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Appliances:
Stove burners, oven, microwave, washer, and dryer working. The kitchen counters also had small appliances which include a toaster, blender, and coffee maker. There is one (1) refrigerator in the home. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. The residence is equipped with central air and heat.

Water Temperature:
The water temperature is 113.4 degrees throughout the kitchen and bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in a cabinet that has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to clients. The client's medications will be stored in a cabinet locked adjacent to the kitchen and inaccessible to clients.

Clients & Staff Files:
The applicant is handling the cash resources of clients and will be in a locked cash box inside the office area. Records of staff and clients will be in a shelving area in the office.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the client's use all stored in the living room, commensurate with the plan of operation.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.

Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 234TH HOME	FACILITY NUMBER: 198320206
	VISIT DATE: 11/05/2021

NARRATIVE

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Fire clearance:
A Fire Clearance inspection was conducted on 09/27/21 with approval for a capacity for two (2) ambulatory, two (2) for non-ambulatory, and zero (0) for bedridden.

Component III:
LPA Dabuet conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

LPAs observed no corrections during this pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been furnished to the applicant, Verretta Boatner. LPA Dabuet will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

>END OF REPORT<

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC809 (FAS) - (06/04)

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