198320271-11-14-2024-11-AS-PSCT-DAZQAQ-20241114110019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320271
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:00:29 AM

Document Has Been Signed on 11/14/2024 11:00 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	PLYMOUTH		FACILITY NUMBER:	198320271
ADMINISTRATOR/ DIRECTOR:	DECKON, BABATUNDE		FACILITY TYPE:	737
ADDRESS:	506 W. PLYMOUTH ST.		TELEPHONE:	(310) 910-0292
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90302
CAPACITY: 4		CENSUS: 1	DATE:	11/14/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:31 AM
MET WITH:	Babatunde Deckon		TIME VISIT/ INSPECTION COMPLETED:	11:30 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 11/14/24, at 9:00am, Licensing Program Analyst (LPA) Perry Scott conducted an announced visit to this home. LPA was greeted by Administrator, Babatunde Deckon for applicant CABA Living LLC, and the LPA explained the purpose of today’s Pre-licensing inspection visit. An application was submitted to CCLD on 09/09/24 for a Change of Ownership for an Enhanced Behavioral Supports Home – ARF, ages 18-59. The applicant requested a capacity of four (4) non-ambulatory individuals. Approved for Delayed Egress. Structure: The home is a four (4) bedroom, two and a half (2.5) bathroom, one-story home with a detached garage situated in a residential neighborhood. The home includes a living room, dining room, family room, kitchen, breakfast nook, office in the garage, and a laundry area. The living area included couches, love seat, and a table. The kitchen has a refrigerator, microwave, and a stove. The rear exterior is fenced throughout with a patio area that includes a table and four (4) chairs. The passageways, walkways, and steps are free from obstructions. The front and back entrances are wheelchair accessible. Bedrooms Residents: The facility has four (4) bedrooms. All rooms include one (1) bed, one (1) chair, one (1) nightstand, and one () table lamp. All bedrooms are equipped with a ceiling light and a dresser. All rooms had closets for ample storage. Facility Evaluation Report Continues on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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 4

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: PLYMOUTH	FACILITY NUMBER: 198320271
	VISIT DATE: 11/14/2024

NARRATIVE

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Bedrooms Staff:
There is no bedroom designated for live-in staff.

Bathrooms:
The home has 2.5 bathrooms. Both bathrooms have a working toilet, and washbasin, the full-size bathroom has a shower with grab bars, non-skid mats, and a chair.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall storage area.

Emergency Phone Numbers, Exit Plan & Menu:
The emergency disaster plan is posted along with the exit plan. There are four (4) fire extinguishers located in the facility. A telephone line is available in the living room. The applicant has submitted a mitigation plan.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet. Food supply is adequately stored in kitchen cabinets and consists of can and other dry goods.

Smoke Detectors:
Smoke/carbon monoxide detectors, and a sprinkler system is located throughout the interior space and are operable.

Facility Evaluation Report Continues on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: PLYMOUTH	FACILITY NUMBER: 198320271
	VISIT DATE: 11/14/2024

NARRATIVE

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Toxins & Kitchen:
All toxins are locked and stored in the laundry area in a cabinet.
Stove burners, oven, microwave, washer, and dryer are working. There is one (1) refrigerator in the kitchen, one (1) in the laundry room, and one (1) freezer in the garage. The refrigerator measured a temperature of at least 45 degrees Fahrenheit for appropriate food storage. The home is equipped with heaters and air conditioning systems.

Water Temperature:

The water temperature measured 106.6F degrees in the kitchen and 112.3F degrees in the bathroom.

Medications, First-Aid Kit & Book:
A first aid kit and manual are stored in the locked medication cabinet which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The client's medications will be stored in the same medication cabinet locked in the kitchen area and inaccessible.

Resident & Staff Files:
The applicant will be handling the cash resources for the clients. Records of staff and clients will be stored in a locked cabinet in the garage/office.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the clients use all stored in the living room and activity room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.

Fire clearance:
A Fire Clearance inspection was conducted on 04/13/2022 and approved for a capacity of four (4) non-ambulatory clients.

Facility Evaluation Report Continues on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: PLYMOUTH	FACILITY NUMBER: 198320271
	VISIT DATE: 11/14/2024

NARRATIVE

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Component III:

LPA and the applicant completed the Component III PowerPoint presentation, which gives an overview of what to expect while running an Adult Residential Facility.

During the Pre-licensing inspection visit, the department did not observe any deficiencies.

An exit interview was conducted, and a copy of this Facility Evaluation Report has been furnished to the Administrator, Babatunde Deckon for applicant CABA Living LLC.

The department will submit a copy of this Facility Evaluation Report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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