198320265-5-9-2022-11-AS-SCIS-CE9P8X-20220509110617

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320265
Report Date: 05/09/2022
Date Signed: 05/09/2022 11:06:31 AM

Document Has Been Signed on 05/09/2022 11:06 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:	PEACH HOSPITALITY ADULT RESIDENTIAL CARE		FACILITY NUMBER:	198320265
ADMINISTRATOR:	JOHNSON, TUNISIA		FACILITY TYPE:	735
ADDRESS:	3501 W. 118TH STREET		TELEPHONE:	(310) 978-8886
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90303
CAPACITY: 6		CENSUS: 0	DATE:	05/09/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Tunisia Johnson-Licensee		TIME COMPLETED:	11:20 AM

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	On 5/9/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Today’s pre-licensing evaluation was conducted with applicant Tunisia Johnson. On 4/7/2022 an initial application was received for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18 to 59 years. The requested capacity is for 6 clients, 6 ambulatory. Facility has a fire clearance for 6 ambulatory clients only. Structure: Facility is a 3-client bedroom, 1- bathroom, 1 one-story house with a 1 car attached garage and an outdoor shaded area in the back yard. The client bedrooms are spacious and easily accommodate the client's furnishings. There is a back patio which contains a table and 6 chairs as well as an umbrella for shade. 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 three bedrooms have two beds, two chairs, overhead lighting, closets and dressers. All drawers comply with the requirement of 8 cubic feet of space. There were no designated staff bedrooms observed. Bathrooms: Bathroom has working toilets, wash basins and shower/bathtub. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillow cases, hand towels, bath towels and wash clothes where observed stored in each bedroom. Continued on 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

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: PEACH HOSPITALITY ADULT RESIDENTIAL CARE	FACILITY NUMBER: 198320265
	VISIT DATE: 05/09/2022

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu: The telephone system has a land line which was called by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on hallway wall. Three fully charged fire extinguishers were found in the facility, two mounted in bedroom hallways and one in the laundry area next to the kitchen.

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 under kitchen sink. Food supply was adequately stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items.

Smoke Detectors: 6 smoke detector and one carbon monoxide detector is present in the facility. All were tested and are fully operational.

Appliances: Oven, microwave, dish washer, washer, and dryer working. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage. The residence is equipped with central heat and air.

Toxins: Locked/stored in the cupboard under the kitchen sink.

Medications, First-Aid Kit & Book: Area for medication storage and records was inspected, they are kept in a locked file cabinet. First aid kit, located in a locked cupboard off of the kitchen area, was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to clients.

Clients & Staff Files: Applicant will be handling clients cash resources, which will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a file cabinet in dining room, section has been inspected along with the available records present.

Reading Material, Games, Equipment & Materials: The facility has board games, puzzles, DVD’s, books, and other recreational materials for the client's use.

Continued on 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

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: PEACH HOSPITALITY ADULT RESIDENTIAL CARE	FACILITY NUMBER: 198320265
	VISIT DATE: 05/09/2022

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Pool/Jacuzzi & Pets: LPA's did not observe any pet or bodies of water at the facility.

Fire clearance: Fire Clearance was approved on 1/14/2022 for 6 ambulatory clients with no special instructions. LPA 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 5/9/2022 at Peach Hospitality Adult Residential, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted, and a copy of this report has been furnished to the applicant.

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 assigned to the applicant.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

LIC809 (FAS) - (06/04)

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