198320257-2-19-2025-11-AS-SDAY-DE2U75-20250219141922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320257
Report Date: 02/19/2025
Date Signed: 02/19/2025 02:19:28 PM

Document Has Been Signed on 02/19/2025 02:19 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:	SCOBEY HOMES #3		FACILITY NUMBER:	198320257
ADMINISTRATOR/ DIRECTOR:	BROWN, AVA		FACILITY TYPE:	735
ADDRESS:	9117 S. 5TH AVE		TELEPHONE:	(866) 290-1781
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90305
CAPACITY: 5		CENSUS: 5	DATE:	02/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Ava Brown, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

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On 02/19/25, Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ava Brown, Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (5) clients of which (4) maybe nonambulatory in rooms #2,3 and #4. Room #1 is for ambulatory only adults ages 18 through 59. Currently, the home has (5) clients. The clients are Westside Regional Center clients. None the clients have Restricted Health Care Conditions, and (1) is non ambulatory. The facility does not handle any of the clients P&I.

The facility is a one family home located in a residential neighborhood. The property consists of the following: 5 client bedrooms, 4 bathrooms, living room, kitchen, dining room, den, washer and dryer and an outdoor shaded area in the front .

LPA conducted a records review of (5) client records, (2) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

At 12:10 pm LPA and Administrator Ava Brown toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured at 110F).

CONT 809-C.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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: SCOBEY HOMES #3	FACILITY NUMBER: 198320257
	VISIT DATE: 02/19/2025

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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued a citation. (See 809-D)

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left wit Administrator, Ava Brown.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/19/2025 02:19 PM - It Cannot Be Edited

Created By: Sparkle Day On 02/19/2025 at 12:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SCOBEY HOMES #3	FACILITY NUMBER: 198320257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) of (record review)], the licensee did not comply with the section cited above that All clients did not have current Medical Assessments on file at time of visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/05/2025
	Plan of Correction
1 2 3 4	Administrator agrees to send a copy of All clients current medical assessment to Sparkle.day@CCL.CA.GOV by due date 3/5/2025

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Janae Hammond

LICENSING EVALUATOR NAME:

Sparkle Day

LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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