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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320253
Report Date: 05/23/2022
Date Signed: 05/23/2022 04:22:23 PM

Document Has Been Signed on 05/23/2022 04:22 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:BEVERLY HOMES - LAWNDALEFACILITY NUMBER:
198320253
ADMINISTRATOR:CHIONG, BEVERLYFACILITY TYPE:
735
ADDRESS:4558 WEST 163RD STTELEPHONE:
(626) 389-7498
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 4CENSUS: DATE:
05/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Beverly ChiongTIME COMPLETED:
03:05 PM
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Licensing Program Analysts (LPA) Jey Cardenas made an announced visit and met with applicant Beverly Chiong to conduct a Pre-Licensing evaluation. An application was received by Community Care Licensing Department (CCLD) on 10/22/21- change of ownership to serve Adults ages 18-59 years; requested capacity is for four (4) ambulatory clients, zero (0) non-ambulatory, and zero (0) bedridden. LPA Cardenas conducted covid-19 risk assessment, based on the assessment the facility is clear of covid-19 infection. This location is currently going through a change of ownership and is currently licensed as SeaBreeze Homes #198600606, there are currently two (2) clients in care.

Structure: Facility is a one story family home located in a residential area, the facility includes: four (4) client bedrooms, two (2) full bathrooms, living room, dining room, kitchen, office nook, attached car garage/ laundry area, outdoor/indoor activity area, shaded patio area, front yard landscape is in good condition at time of visit.

Bedroom Residents: Bedrooms are equipped with one bed per client, night-stand, chair, and overhead lightning. Bathrooms: Two (2) bathrooms have a working toilet, wash basin, and a bathtub. There will be zero (0) live in staff. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Three two fully charged fire extinguishers located in the dinning room, and down the hall near bedroom#4. LPA observed two plastic containers with sufficient hygiene supplies for clients. LPA observed activities available for clients. Staff files/ client files and medication will be stored in locked tall cabinet which will be located in the office space, first aid kit, and first aid manual available at time of visit. Facility has sanitation station located front entrance.

Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in kitchen cabinet inaccessible and under lock. Smoke Detectors/Carbon Monoxide(s): Facility is equipped with operational dual and hardwired smoke detectors/ carbon monoxide in all bedrooms and mounted on the ceiling in the hallway. LPA observed

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: BEVERLY HOMES - LAWNDALE
FACILITY NUMBER: 198320253
VISIT DATE: 05/23/2022
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two-day perishables, and seven day supply of non-perishable food. Appliances: Stove burners (gas), oven, microwave are in working condition. There is one working (1) refrigerator in the home.

During the pre-licensing inspection five times were observed that need correction:

1. Water temperature measured at 145.8 degrees F.

2. Backyard and front porch needs de-cluttering.

3. Sketch that was in the packet didn’t match actual physical plant, submit updated sketch.

4. See something say something complaint poster not available.

5. Side gate is locked by a chain, facility is not approved for locked perimeters.

2 weeks to correct items- 6/3/22.



LPA reminded applicant the following items shall be posted always: Emergency numbers, Personal rights, Emergency Disaster Plan, Complaint Procedures, and facility sketch show emergency exits.

An exit interview was conducted, and a copy of this report has been furnished to the Sudan David. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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