198320285-5-4-2023-11-AS-MBRN-CRHUU4-20230504155256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320285
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:53:12 PM

Document Has Been Signed on 05/04/2023 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	HOUSE OF LEGACY		FACILITY NUMBER:	198320285
ADMINISTRATOR:	MARTIN, LATIESHA		FACILITY TYPE:	735
ADDRESS:	1522 S WADSWORTH AVENUE		TELEPHONE:	(310) 213-1956
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 4		CENSUS: 3	DATE:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Latiesha Martin		TIME COMPLETED:	04:00 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 5/4/2023, Licensing Program Analyst LPA Martessa Browns conducted an unannounced visit to the Looking Ahead facility for the purpose of a pre-licensing evaluation. LPA was greeted and accompanied by Latiesha Martin Administrator. The facility is licensed to operate for (4) non-ambulatory developmentally disabled or Mentally Ill adults ages 18 through 59. Currently, the home has (3) clients. The clients are from: South Central Los Angeles Regional Center.

The facility is a single-story structure located in a residential neighborhood. The home consists of 5 Bedrooms and 1 of the bedrooms is utilize for the office. All client rooms were checked. All beds and mattress and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Windows, dresser and closet were inspected. Medication and Mars were locked in a storage room observed in the hallway. Bed linens, comforters and bath towels were adequately stocked at the time of visit located in the hallway. Bathrooms were inspected toilets and water faucets worked properly. Shower were in good condition, there is adequate lighting, and sufficient toiletries accessible to clients and soap.The water temperature in bathroom #1 measured at 120 F and Bathroom #2 119 F, all bathrooms had grip mats and was clean. All smoke detectors were check and operational. Kitchen area was inspected with perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors combo were observed and operational. Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. LPA toured the outside of the premises was free from obstruction and passageways were clear. Facility had additional hygiene supplies, refrigerator and deep freezer located in as storage area on the side of the house.

LIC 809 is on the next page

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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 6

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: HOUSE OF LEGACY	FACILITY NUMBER: 198320285
	VISIT DATE: 05/04/2023

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

LPA reviewed cash resources for clients. Cash resources was locked and stored, in a file cabinet with P & I Ledger, accessible to designated staff only. Files for clients and staff were locked.

LPA conducted a records review of (3) client records, (5) staff records and interviews were conducted. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

Exit interview was conducted and provided to Latiesha Martin.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6