198320230-1-3-2022-11-AS-GJON-CABQGX-20220103111017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320230
Report Date: 12/30/2021
Date Signed: 01/03/2022 11:11:36 AM

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:	ACTIVE BOARD + CARE, LLC		FACILITY NUMBER:	198320230
ADMINISTRATOR:	MICHELSON, CANDICE		FACILITY TYPE:	740
ADDRESS:	3412 W. 187TH PL		TELEPHONE:	(310) 999-1937
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 0	DATE:	12/30/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee - Candice Michelson		TIME COMPLETED:	01:00 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 12/30/21, Licensing Program Analysts (LPAs) Gail Johnson and Don Senaha conducted an announced visit to this home. LPA’s were greeted by applicant Candice Michelson and planned staff Steven Michelson. LPA Johnson explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 09/13/21. In the initial license application for a Residential Facility for Adults, ages ranging from 60 years and older. The applicant requested for a capacity of six (6) individuals 5 non-ambulatory residents and one bedridden resident. Structure: The home is a three (3) bedroom, two (2) bathroom, one-story home in a residential neighborhood. The home is a gray color structure that includes a living, dining, kitchen, and laundry area. The living area has a (sofa, table, and recliner) and kitchen (granite counter tops, refrigerator and stove). The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. The patio is accessible with a table and four (4) chairs and an umbrella for shade. Bedrooms Residents: The facility had three (3) bedrooms for residents. There are three (3) bedrooms for 5 non-ambulatory residents and one bedridden resident. All rooms include (2) two twin beds, one (1) chair, and two (2) night stands. All bedrooms are equipped with ceiling fans and 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

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail Johnson	TELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

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: ACTIVE BOARD + CARE, LLC	FACILITY NUMBER: 198320230
	VISIT DATE: 12/30/2021

NARRATIVE

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Bathrooms:
The home has two (2) bathrooms. Bathroom #1 is accessible to bedrooms #1-#2 through a hallway. Bathroom #2 is located in bedroom #3. Hallway bathroom has grab bars. All bathrooms have a working toilet, washbasin, and shower 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’s one fire extinguisher located in the kitchen and fully charged.

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 the activity room. Food supply is stored in kitchen cabinets and consists of can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space are hardwired. Smoke detectors are located in all three (3) bedrooms and hallways.

Toxins:
All toxins are locked/stored outside the facility.

Appliances:
Stove burners, oven, microwave, washer, and are working dryer working. The kitchen counters also had small appliances which include two coffee makers. There are two (2) refrigerators in the home. The refrigerator has a measured temperature of at least 33 degrees Fahrenheit for appropriate food storage. The residence is equipped with central air and heat.

Evaluation Report Continues

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail Johnson	TELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

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
MONTEREY PARK, CA 91754

FACILITY NAME: ACTIVE BOARD + CARE, LLC	FACILITY NUMBER: 198320230
	VISIT DATE: 12/30/2021

NARRATIVE

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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 not handling cash resources for clients. Records of staff and clients will be in a locked file cabinet in the office.

Reading Material, Games, Equipment & Materials:
The facility has 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 is one dog and no jacuzzi, or pool in the fenced area.

Fire clearance:
A Fire Clearance inspection was conducted on 10/21/21 with approval for a capacity for five 5) non-ambulatory, one (1) bedridden.

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

Evaluation Report Continues

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail Johnson	TELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC809 (FAS) - (06/04)

Page: 4 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
MONTEREY PARK, CA 91754

FACILITY NAME: ACTIVE BOARD + CARE, LLC	FACILITY NUMBER: 198320230
	VISIT DATE: 12/30/2021

NARRATIVE

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LPAs observed the following necessary corrections during this visit:
87208 Plan of Operation - (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for non-ambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e)

87311 Telephones
All facilities shall have telephone service on the premises.

The following needs to implemented for this facility to be approved as a licensed facility:
1. Licensee agreed to make the correction to the bedridden bedroom. Licensee agreed to provide a picture of the bedridden bedroom that has two beds (Due 1/15/22).
2. Licensee agreed to make the correction to the facility sketch. The sketch will be completed by the licensee with labeling the room east of the garage as an activity room (Due 1/15/22).
3. Licensee agreed to provide a land line to the facility (Due 1/15/22).

An exit interview was conducted, and a copy of this report has been furnished to the applicant, Candice Michelson. LPA Johnson 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<

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail Johnson	TELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC809 (FAS) - (06/04)

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