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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320238
Report Date: 11/13/2023
Date Signed: 11/13/2023 10:53:20 AM

Document Has Been Signed on 11/13/2023 10:53 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:KNOAH'S HOME LLCFACILITY NUMBER:
198320238
ADMINISTRATOR:TILLMAN, CAYLAFACILITY TYPE:
735
ADDRESS:1431 W 97TH STTELEPHONE:
(323) 303-9808
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 0DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:19 AM
MET WITH:Cayla TillmanTIME COMPLETED:
11:20 AM
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On 11/13/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual required visit using the New Inspection Control Tools. LPA was met by Cayla Tillman, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve 4 developmentally disabled clients (age 18-59).

There are currently no (0) clients in placement. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 1 bathroom, dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry area and a detached garage.

LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 116.9F in the bathroom. A comfortable temperature is maintained in the facility. LPA Richard observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Both fire extinguishers were fully charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff was wearing face covering, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

See LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KNOAH'S HOME LLC
FACILITY NUMBER: 198320238
VISIT DATE: 11/13/2023
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LPA Richard advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. The facility fees are current.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Cayla Tillman.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
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