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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320257
Report Date: 02/28/2022
Date Signed: 02/28/2022 12:14:40 PM

Document Has Been Signed on 02/28/2022 12:14 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:SCOBEY HOMES #3FACILITY NUMBER:
198320257
ADMINISTRATOR:BROWN, AVAFACILITY TYPE:
735
ADDRESS:9117 S. 5TH AVETELEPHONE:
(866) 290-1781
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY: 6CENSUS: 0DATE:
02/28/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ava Brown, AdministratorTIME COMPLETED:
12:05 PM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 5
Census (if any clients in care): None
COMP II Participants: Ava Brown, Administrator
Interview Method: Telephone interview

On February 28, 2022, Administrator participated in COMP II. Identification of the Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Applicant/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

Exit interview conducted with Administrator. Administrator informed to return signed PDF copy to Analyst by close of business today, 2/28/2022.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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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