198320282-5-4-2022-11-AS-EDAT-CE4UU8-20220504155308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320282
Report Date: 05/04/2022
Date Signed: 05/04/2022 03:53:26 PM

Document Has Been Signed on 05/04/2022 03:53 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ACOSTA FAMILY HOME II		FACILITY NUMBER:	198320282
ADMINISTRATOR:	ACOSTA, ASHLEY		FACILITY TYPE:	735
ADDRESS:	1811 EAST ABILA STREET		TELEPHONE:	(310) 604-8740
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 4		CENSUS: 0	DATE:	05/04/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:19 PM
MET WITH:	ASHLEY ACOSTA		TIME COMPLETED:	03:27 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 05/04/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an announced visit to this home. LPA was greeted by applicant Ashley Acosta and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 02/25/22. In the initial license application for a Residential Facility for Adults, ages ranging from 18-59 years old. The applicant requested for a capacity of four (4) individuals, of which two (2) ambulatory, two (2) non-ambulatory, and zero (0) bedridden. Structure: The home is a six (6) bedroom, three (3) bathroom, one-story home with a one (2) car garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The living room area has a fireplace. The living area included sofas and a table. The kitchen has marble countertops with a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Clients: The facility had four (4) bedrooms for clients. All rooms include (1) a full-size or queen size bed, one (1) chair, one (1) nightstand, one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Evaluation Report Continues

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ACOSTA FAMILY HOME II	FACILITY NUMBER: 198320282
	VISIT DATE: 05/04/2022

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

Bedrooms Staff:
There are two-bedroom designated for live-in staff.

Bathrooms:
The home has three (3) bathrooms. Bathroom #1 is accessible to bedrooms #1 and #2 through a hallway. Bathroom #2 is accessible to bedrooms #3 and #4. One (1) bathroom is designated for staff only. All bathrooms have a working toilet, washbasin, and shower with non-skid mats.

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 closet adjacent to the client’s bedrooms.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There is two (2) fire extinguisher located in the kitchen mounted on the wall and garage. A telephone line is available in the living room. Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant submitted a Mitigation Plan on 02/22/22.

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 drawer. Food supply is adequately stored in kitchen cabinets and consists of the can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all four (4) bedrooms and hallways. Carbon monoxide is built-in with the smoke detectors.

Toxins:
All toxins are locked and stored under the kitchen sink cabinet.

Evaluation Report Continues

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ACOSTA FAMILY HOME II	FACILITY NUMBER: 198320282
	VISIT DATE: 05/04/2022

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

Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which include a toaster, rice cooker, and a blender. There is one (1) refrigerator in the home. The refrigerator measured a temperature of at least 45 degrees Fahrenheit for appropriate food storage. A second refrigerator is located in the garage for backup food supplies. The home is equipped with central heaters and air conditioning systems.

Water Temperature:
The water temperature is 109.7 degrees throughout the kitchen and bathrooms.

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

Clients & Staff Files:
The applicant is handling the cash resources of clients safeguarded and recorded in the P&I binder. Records of staff and clients will be stored in a cabinet along with medications in the kitchen cabinet.

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

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

Evaluation Report Continues

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ACOSTA FAMILY HOME II	FACILITY NUMBER: 198320282
	VISIT DATE: 05/04/2022

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

Fire clearance:
A Fire Clearance inspection was conducted on 04/20/22 with approval for a capacity for three (2) non-ambulatory, one (2) ambulatory, and zero (0) bedridden.

Component III:
LPA Dabuet conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

LPA observed no corrections during this pre-licensing inspection.

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

END OF REPORT

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4