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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320245
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:13:28 PM

Document Has Been Signed on 10/24/2024 12:13 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ALLEN'S ADULT CARE FACILITY, INCFACILITY NUMBER:
198320245
ADMINISTRATOR/
DIRECTOR:		ALLEN, III, LEROYFACILITY TYPE:
735
ADDRESS:1712 N. GRAPE AVENUETELEPHONE:
(310) 635-1661
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 6CENSUS: DATE:
10/24/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:56 AM
MET WITH:Leroy AllenTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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On 10/24/2024, Licensing Program Analyst’s (LPA’s) Yolanda Rosser met with and toured the facility with Licensee Leroy Allen. The facility plans to support individuals who are 18 - 59 years of age. The facility has a fire clearance for (6) ambulatory clients.

The facility is a single-story with three (3) bedrooms and (1) restroom. LPA Rosser observed the following during a tour of the facility: living room/dining room, and kitchen. The areas inspected have the required furnishings, lighting, and storage. The required perishable and non-perishable food supply was observed. LPA Rosser toured the garage. The patio area is located in the backyard and is shaded. The front yard landscape is clean and free of any hazards. The walkways around the facility are free of obstructions.

LPA Rosser conducted a test of the smoke and carbon monoxide detectors and found them to be functioning properly. LPA Rosser conducted a test of the water temperature in the bathroom and kitchen. The water temperature registered at 112-115 °F. LPA Rosser observed inaccessible storage areas for medications, sharp objects. All fire extinguishers were charged and operable.

Continued on 809C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ALLEN'S ADULT CARE FACILITY, INC
FACILITY NUMBER: 198320245
VISIT DATE: 10/24/2024
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During this visit LPA Rosser found the following corrections are needed:
  • LPA observed a down power line located in the backyard. Licensee will repair or replace down power line observed in facility in backyard area. This correction will require the assistance of a public utility company. Licensee will provide a photograph of correction and submit this to CCL.
  • LPA observed closet in the hallway is storing chemical hygiene products. Licensee will remove products to a secured location or provide inaccessibility and secured closet doors for these products. Licensee will provide a photograph of correction and submit to CCL.

The Component III was completed during this visit.

An exit interview was conducted, and a copy of this report was provided to Licensee/Leroy Allen.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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