198320255-4-12-2023-11-AS-MBRN-CQTRCR-20230412125445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320255
Report Date: 04/12/2023
Date Signed: 04/12/2023 12:55:06 PM

Document Has Been Signed on 04/12/2023 12:55 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	FAITHFUL ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198320255
ADMINISTRATOR:	REDMOND, SHAFUN		FACILITY TYPE:	735
ADDRESS:	2073 EAST BLISS STREET		TELEPHONE:	(310) 597-3152
CITY:	COMPTON	STATE: CA	ZIP CODE:	90222
CAPACITY: 4		CENSUS: 0	DATE:	04/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Derwoynia Redmond-Licensee		TIME COMPLETED:	01:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA), Martessa Brown and Licensing conducted an announced visit to the facility for purpose of a pre-licensing evaluation and LPA met with Derwoynia Redmon. An application was submitted to CCLD on 11/22/22 for Initial license for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18 to 59 years. The requested capacity is for 4 ambulatory clients. Facility is 5 bedrooms, and one will be utilized as a staff room, 2 bathrooms, single story house with no garage. The client bedrooms are spacious and will easily accommodate the client's furnishings. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: All Bedrooms are for 4 ambulatory clients. Bedroom #1, #2, #3 and #4 each have one bed, one chair, one-night stand, one lamp in addition to overhead lighting. There is one dresser with two drawers in Bedrooms #1, #2, # and #4 which comply with the requirement of 8 cubic feet of space. There were no designated staff bedrooms observed. Bathrooms: Bathrooms #1 and #2 have a working toilet, wash basins and showers. LPA observed adequate lighting in hallway leading to bathrooms #2. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet. Emergency Phone Numbers, Exit Plan & Menu: The telephone system has a land line. Emergency Disaster Plan and "See something, Say something Let Us Know" posted & readily available for review on the wall between the living room and kitchen. Menu available for review located in a locked kitchen cabinet opposite the refrigerator. Fire Extinguisher mounted on the kitchen wall opposite postings. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet located in the kitchen area. Food supply inadequate but applicant will increase inventory; stored in kitchen refrigerator and cabinets and consists of the following: A variety of Fresh and Canned fruit, vegetable and meat food items. 809-C is on the next page

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FAITHFUL ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198320255
	VISIT DATE: 04/12/2023

NARRATIVE

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Smoke Detectors: 5 smoke detectors are battery with Carbon monoxide. Appliances: Stove burners, oven, microwave, washer, and dryer working. There are 1 refrigerator in the home, one in the kitchen and one in the garage for additional food storage. Refrigerator in the kitchen has a measured temperature of at least 53 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: Locked/stored in the storage room located in the cabinet hallway. Water Temperature: Tested at 115 F and 114 F degrees. Medications, First-Aid Kit & Book: Medication administration records and first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in locked kitchen cabinet adjacent the refrigerator, available for staff use but inaccessible to clients. Clients & Staff Files: Applicant will be handling cash resources of clients and has a surety bond for $3,000.00. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked in staff office and the section has been inspected along with the available records present.

Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. Activity board is posted on the wall between the kitchen and the living room. Pool/Jacuzzi & Pets: LPA did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 8/5/22 for 4 Ambulatory with no special instructions. LPA did not observe delayed egress, chain locks or dead bolts on exits. LPAs did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Component III: Conducted at the Pre-Licensing visit on 4/12/23 at Faithful Adult Residential Facility, information provided about how to operate the facility within substantial compliance.
During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA, Martessa Brown by 4/21/23. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date.
Licensee/Administrator will have patio cover contained 1 table and 4 chairs sent to LPA by 4/21/23.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA Martessa Brown 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 assigned to their application.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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