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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320285
Report Date: 04/08/2022
Date Signed: 04/11/2022 08:18:17 AM

Document Has Been Signed on 04/11/2022 08:18 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
MONTEREY PARK, CA 91754
FACILITY NAME:HOUSE OF LEGACYFACILITY NUMBER:
198320285
ADMINISTRATOR:MARTIN, LATIESHAFACILITY TYPE:
735
ADDRESS:1522 S WADSWORTH AVENUETELEPHONE:
(310) 213-1956
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 4CENSUS: 0DATE:
04/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Latiesha MartinTIME COMPLETED:
02:55 PM
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On 4/8/22 at 12:00 pm, Licensing Program Analyst LPA/ Susan Campos conducted an announced visit to the Looking Ahead facility for the purpose of a pre-licensing evaluation. LPA was greeted and accompanied by Latiesha Martin Administrator for the pre-license inspection.

An application for change of address location was submitted to CCLD on 3/25/2022 for an initial license application for an Adult Residential Facility to serve Developmentally Disabled Adults, ages from 18 to 59 years. The applicant requested for a capacity for four (4) ambulatory individuals.

Structure:


Facility has 5 (5) bedrooms (4 client bedrooms and 1 staff office) and (2) bathrooms, it is single story house. The facility is a teal color, smooth stucco structure with white trim home with an open floor plan which includes: living room, dining room, and kitchen. The interior has recess lighting throughout. The living area had no fireplace. The living room includes: (2) recliner chairs, sofa, coffee table, Large screen TV with cable. The kitchen has granite counter tops with refrigerator, stove/ microwave, dishwasher, blender, coffee maker, food processor, rice cooker, and crockpot cooker. During the visit, LPA noticed passageways, walkways steps and patios are free from obstructions. LPA observed a backyard table and four chairs with umbrella and backyard grass area. In addition, basketball net, stationary bike, and exercise trampoline jumper.

Bedrooms Clients
The facility has four (4) bedrooms for ambulatory clients. Rooms #1-3 have one (1) chair, (1) full size bed, one (1) nightstand, one (1) table lamp. Room #4 has one (1) chair, (1) queen size bed-movement retract mattress. All rooms have dressers, which complies with the requirement of 8 cubic feet of space. All rooms also have closets for ample storage. All bedrooms are equipped with a remote-control ceiling fan.

Report Continued on LIC 809C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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 3
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: HOUSE OF LEGACY
FACILITY NUMBER: 198320285
VISIT DATE: 04/08/2022
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Fire clearance:

Fire Clearance with approval on 4/7/22 for a capacity for four (4) ambulatory clients. The (2) fire extinguishers, and (7) smoke detectors and (3) carbon monoxide were checked and found to be operable.



Component III:
LPA / Campos conducted at the Pre-Licensing visit; 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, Latiesha Martin. Accordingly, LPA/ Campos 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: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
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
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE OF LEGACY
FACILITY NUMBER: 198320285
VISIT DATE: 04/08/2022
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Appliances:
Stove burners, oven, dishwasher, microwave, washer, and dryer are working. The kitchen counters also has small appliances which included: toaster, coffee maker, blender, food processor, crock pot and rice cooker. There is one (1) refrigerator in the home. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at zero degrees Fahrenheit. The residence is equipped with central AC/heating.

Toxins:


All toxins are locked/stored in a laundry room cabinet.

Water Temperature:
Bathroom #1 hot water measured at 105 degrees Fahrenheit and Bathroom #2 hot water measured at 105 degrees Fahrenheit.

Medications, First-Aid Kit & Book:
A first aid kit stored in the kitchen has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual locked and inaccessible to clients. Client's medications will be stored in a locked kitchen cabinet office locked and inaccessible to clients.

Clients & Staff Files:

Applicant will be handling cash resources for clients. Cash resources will be locked and stored, in a file cabinet with P & I Ledger, accessible to designated staff only. Files for clients and staff will be stored and locked in a cabinet in the staff office.

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 living room cabinet, commensurate with the plan of operation.

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

Continued on LIC 809C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
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