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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320282
Report Date: 08/07/2023
Date Signed: 08/09/2023 07:25:13 AM

Document Has Been Signed on 08/09/2023 07:25 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ACOSTA FAMILY HOME IIFACILITY NUMBER:
198320282
ADMINISTRATOR:ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:1811 EAST ABILA STREETTELEPHONE:
(310) 604-8740
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
08/07/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ashley AcostaTIME COMPLETED:
10:31 AM
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On 08/07/23 at 10 am, an office informal meeting was conducted with Administrator/Licensee Ashley Acosta, through Microsoft Teams. A virtual conference call and in attendance are Licensing Program Manager (LPM) Janae Hammond, and Licensing Program Analyst (LPA) Ernand Dabuet. The purpose of this meeting was to discuss the standard procedures for operations of all three Acosta Family Homes I, II, and III.

Administrator/Licensee Acosta stated being responsible for overseeing as the administrator for all homes #198320286, #198320282, and #198602219. Currently, the homes do not have an appointed Designation of Facility Responsibility LIC 308 on file with Community Care Licensing (CCL) for all group homes. Acosta noted that #198320286, and #198320282 remained as Level 2 with Harbor Regional Center consumers, and #198320282 remained as Level 4 with South Center Los Angeles Center consumers.

To ensure that all staff are current with Direct Support Provider (DSP) Training 1 and 2, the topic of staffing was discussed for all homes. During the office meeting (LPM) Hammond conducted a brief overview of the terms and conditions to comply with Administrator Qualifications, Personnel Requirements and Personnel Records. Discussions of staffing requirements, in which the following items were emphasized:

· Submit a Personnel Report LIC 500 for all three (3) group homes.
· Submit Designation of Facility Responsibility LIC 308 for all three (3) group homes.
· Submit a plan to address staffing shortage.
· Ensure all personnel records are complete.
· Ensure all staff have completed DSP Trainings.
· Non-Enforcement Program from (CCLD) Technical Support Program (TSP)

Evaluation Report continues LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282
VISIT DATE: 08/07/2023
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A time frame was agreed upon during this meeting that within 30 days 09/07/23, information will be submitted for the regional office for review. In addition, unannounced Case Management visits may be required.

A Non-Enforcement Program from (CCLD) Technical Support Program (TSP) was offered for assistance. (TSP) can be access through the link below:

https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers

The meeting concluded at 9:31 am. An exit interview was conducted, and the report was provided by email to Ashley Acosta.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023
LIC809 (FAS) - (06/04)
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