<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320265
Report Date: 05/10/2023
Date Signed: 05/10/2023 01:49:14 PM

Document Has Been Signed on 05/10/2023 01:49 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:PEACH HOSPITALITY ADULT RESIDENTIAL CAREFACILITY NUMBER:
198320265
ADMINISTRATOR:JOHNSON, TUNISIAFACILITY TYPE:
735
ADDRESS:3501 W. 118TH STREETTELEPHONE:
(310) 978-8886
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Tunisia JohnsonTIME COMPLETED:
02:00 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
On 5/10/2023 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to the facility for the purpose of a Required - 1yr inspection. Today’s pre-licensing evaluation was conducted with Licensee Tunisia Johnson.

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.

LPA and Licensee inspected the bedrooms. There are 3 bedrooms, with accommodating chairs, overhead lighting, closet and dressers.


LPA and licensee toured the hallway bathroom. LPA found the bathroom to be clean, paper towels and soap. There was a functioning toilet with handrails and shower. The water delivered at 118.7.


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.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PEACH HOSPITALITY ADULT RESIDENTIAL CARE
FACILITY NUMBER: 198320265
VISIT DATE: 05/10/2023
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
26
27
28
29
30
31
32
Oven and microwave were both working and in good condition. There is 1 refrigerator in the kitchen and washer and dryer on the service porch. The residence is equipped with central heat and air.

Cleaning fluids and toxins were locked/stored in the cupboard under the kitchen sink.

An exit interview was conducted, and a copy of this report has been furnished to Tunisia Johnson
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2