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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320245
Report Date: 01/06/2022
Date Signed: 01/06/2022 01:41:19 PM

Document Has Been Signed on 01/06/2022 01:41 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ALLEN'S ADULT CARE FACILITYFACILITY NUMBER:
198320245
ADMINISTRATOR:ALLEN, LEROY IIIFACILITY TYPE:
735
ADDRESS:1712 N. GRAPE AVENUETELEPHONE:
(931) 635-1661
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 6CENSUS: 0DATE:
01/06/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leroy Allen III & Latrice WilliamsTIME COMPLETED:
01:30 PM
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Facility Type: ARF Application Type: INITL Capacity: 6
COMP II Participants: Allen, Leroy III (Corporate Board Member and Administrator) and Williams, Latrice (Corporate Board Member)
Interview Method: Telephone interview
On 1/6/22, applicant(s) and administrator participated in COMP II. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant(s') and Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Bailey Humes
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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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