198320247-4-20-2022-11-AS-LMOA-CDNMRU-20220420095051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320247
Report Date: 04/19/2022
Date Signed: 04/20/2022 09:51:01 AM

Document Has Been Signed on 04/20/2022 09:51 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	PERSON CENTERED OPTIONS, LLC		FACILITY NUMBER:	198320247
ADMINISTRATOR:	THOMPSON, TIKI		FACILITY TYPE:	735
ADDRESS:	1762 W. 244TH STREET		TELEPHONE:	(909) 904-2913
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 4		CENSUS: 0	DATE:	04/19/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	TIKI THOMPSON		TIME COMPLETED:	11:45 AM

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On 4/19/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an announced visit to this home. LPA was greeted by Applicant Tiki Thompson and explained the purpose of today’s pre-licensing inspection visit.

An application was submitted to CCLD on 1/26/2022 for an Initial Application for an Adult Residential Facility. The applicant requested a capacity of four (4) of which three (3) are non-ambulatory individuals.

Structure:
The facility is a one-story house located in a residential neighborhood and consists of four (4) bedrooms, two (2) bathrooms, two (2) car garage, living room, family room, dining area, and kitchen. The facility is clean, sanitary, and in good repair. Protective devices are in place to include non-slip material on rugs. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees. LPA observed non-hazard tankless water heater and a cooling/heating tank on the west side of the premises.

Bedrooms (Residents):

The facility has three (3) bedrooms for non-ambulatory clients and one (1) bedroom for an ambulatory client. All rooms include (1) a bed, one (1) chair, one (1) nightstand, and one (1) table lamp. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath, or toilet.

Bedrooms (Staff):

There are no staff bedrooms.

Bathrooms:
The home has two (2) bathrooms. All resident bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Evaluation Report Continued in LIC809-C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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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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: PERSON CENTERED OPTIONS, LLC	FACILITY NUMBER: 198320247
	VISIT DATE: 04/19/2022

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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 the closet adjacent to the client’s bedrooms and bathroom.

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 is one (1) fire extinguisher last serviced on 3/14/2022 located in the family room near the exit door. A telephone line is available in the kitchen (424-305-4002). Emergency supplies are stored in the garage. The applicant’s Mitigation Plan was approved on 4/4/2022.

Food Service:
All kitchen areas are clean and free of litter, rodents, vermin, and insects. The refrigerator and freezer are clean and of adequate size. The freezer is maintained at 0 degrees Fahrenheit and the refrigerator is below the required maximum of 40 degrees Fahrenheit. A two (2) day supply of perishable foods and a seven (7) day supply of non-perishable food were observed. All equipment, appliances, dishes, and utensils are clean and well maintained.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space are operable.

Toxins:
All toxins are locked and stored under the kitchen sink cabinet.

Water Temperature:
The water temperature is 115.7 degrees in the resident bathrooms.

Report Continued in LIC809-C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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: PERSON CENTERED OPTIONS, LLC	FACILITY NUMBER: 198320247
	VISIT DATE: 04/19/2022

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Medications, First-Aid Kit & Book:
A first aid kit is stored in a locked cabinet 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 locked cabinet in the laundry/kitchen area.

Clients & Staff Files:
The applicant will be handling the cash resources of the clients and will be stored in a locked cabinet in the family room. Records of staff and residents will be stored also in the same locked cabinet in the family room.
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.

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

Fire clearance:
A Fire Clearance inspection was conducted on 3/15/2022 with approval for a capacity of four (4) of which three (3) are non-ambulatory.

Component III:
The applicant completed the Comp III training during today’s visit.

The following items need to be corrected prior to licensure. Proof of corrections shall be submitted to Licensing by 4/22/2022.

* Metal linings with sharp edges at the bottom of the wall on the open porch between the two exit doors towards the backyard.
* PUB 475 must be in size 20X26
* Cabinets for linens
* Handwashing poster for each bathroom
* 30-day PPE supplies

An exit interview was conducted, and a copy of this report has been furnished to Applicant Tiki Thompson.

END OF REPORT

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC809 (FAS) - (06/04)

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