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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320285
Report Date: 04/09/2025
Date Signed: 04/09/2025 02:15:58 PM

Document Has Been Signed on 04/09/2025 02:15 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HOUSE OF LEGACYFACILITY NUMBER:
198320285
ADMINISTRATOR/
DIRECTOR:		MARTIN, LATIESHAFACILITY TYPE:
735
ADDRESS:1522 S WADSWORTH AVENUETELEPHONE:
(310) 213-1956
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 4CENSUS: 4DATE:
04/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Annielyn Dumas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 04/09/2025 at 8:45am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Annielyn Dumas, Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for adults ages 18 thru 59 years, approved for four (4) ambulatory online. Currently, the home has (4) clients. The clients are South Central Los Angeles Regional Center (SCLARC) clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facility has a annual fee are current. The liability insurance is with Philadelphia Insurance Co. and policy # PHPK2630089-011 effective 12/06/2024 - 12/06/2025 with each occurrence at $1,000,000 and general aggregate $3,000,000.

The facility is a single story home located in a residential neighborhood. The property consists of the following: 4 client bedrooms, 2 bathrooms, one (1) office, living room, kitchen, dining room, a laundry area, a medication room with extra linen, an attached garage with an additional refrigerator, deep freezer and extra cleaning products and a backyard patio area with a shed with outdoor supplies and two (2) outdoor shaded area.

Between the hours of 9:35am - 11:00 am LPA conducted a records review of (4) client records, (4) staff records, (3) clients Personal & Incidental Records, (4) Client Medication Administration Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit and did not observed any discrepancies at the time of visit. The last fire drill was conducted on 02/18/2025

Report continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HOUSE OF LEGACY
FACILITY NUMBER: 198320285
VISIT DATE: 04/09/2025
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Between the hours of 9:15am - 9:32am LPA and Pamela Williams (DSP) toured the inside and outside of the facility. All client rooms were checked. Mattresses 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. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly.Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F ( Bathroom #1: 118.2 F, Bathroom #2 107.2F, & Kitchen 118.2 F).

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, 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. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did not observe any deficiencies.

An exit interview was conducted with Annielyn Dumas and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
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