198320286-4-12-2022-11-AS-SCAS-CDELQP-20220412085753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320286
Report Date: 03/25/2022
Date Signed: 04/12/2022 08:58:06 AM

Document Has Been Signed on 04/12/2022 08:58 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:	ACOSTA FAMILY HOME I		FACILITY NUMBER:	198320286
ADMINISTRATOR:	ACOSTA, ASHLEY		FACILITY TYPE:	735
ADDRESS:	1540 EAST CYRENE DRIVE		TELEPHONE:	(310) 997-5743
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 4		CENSUS: 3	DATE:	03/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Ashley Acosta		TIME COMPLETED:	02:00 PM

NARRATIVE

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On 03/25/22 at 12:00pm, Licensing Program Analyst LPA/ Susan Campos conducted an announced visit to the facility for purpose of a pre-licensing evaluation. The LPA was allowed entrance into the facility by Administrator Ashley Acosta. The LPA and Ms. Acosta, conducted a walk through of the facility for the pre-license inspection.

An application for change of ownership was submitted to CCLD on 1/26/22, for a change of ownership license application for an Adult Residential Facility to serve Developmentally Disable Adults, ages ranging from 18 to 59 years. The applicant requested for a capacity for four (4) ambulatory individuals. Currently, the facility has 3 clients living in the facility. The home is vendorized level 4I through the Harbor Regional Center.

Structure:

The home consists of 6 bedrooms and 4 bathrooms (3 client bedrooms, 2 full bathrooms, and 3 staff rooms, and 2 staff bathroom). Facility is a two story house in a residential neighborhood. The facility is a tan stucco structure with a floor plan which includes: living room, dining room, kitchen, family den, activity/ theater/ laundry/ storage room. The interior has lighting throughout. The living area has non-operational working fireplace. The living area also included (1) sofa/ (2) Accent chairs and a side table, cabinet and coffee table. The kitchen has granite counter tops with refrigerator, stove/ microwave, and on counter toaster, coffee machine and blender. Den/ family room has large screen television, with (2) sofas, cabinets, and recreational games, coffee table. Activity/ Theater room has two sofas, large projection screen, table and chairs, sink, counter, refrigerator, and storage area including emergency food and water. During the visit, LPA noticed passageways, walkways steps and patios are free from obstructions. LPA observed a covered back yard deck with patio cover table and chairs, and a second patio area with table, chairs and umbrella.

Report Continued on LIC 809C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

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

FACILITY NAME: ACOSTA FAMILY HOME I	FACILITY NUMBER: 198320286
	VISIT DATE: 03/25/2022

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locked in activity room 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 den room cabinet, commensurate with the plan of operation.

Pool/Jacuzzi & Pets:

There are two dogs that live in the back yard in fenced area. No jacuzzi or pool the back yard.

Fire clearance:

Fire Clearance on 2/28/22, approval for a capacity for four (4) clients, fire extinguishers, and smoke detectors 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 Administrator, Ashley Acosta. 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: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

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: ACOSTA FAMILY HOME I	FACILITY NUMBER: 198320286
	VISIT DATE: 03/25/2022

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Bedrooms Clients:

The facility had three (3) bedrooms. All client bedrooms #1-#3 have one (1) chair, one (1) full size bed, one (1) night stand, one (1) table lamp, and (1) dresser, complies with the requirement of 8 cubic feet of space.

All rooms also have closets for ample storage.

Appliances:

Stove burners, oven, microwave, convention oven washer, and dryer are working. The kitchen counters also had small appliances which included: toaster, coffee maker, and blender. 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 under kitchen cabinet sink, and Laundry room cabinet.

Water Temperature:

Bathroom hot water tested at 117.9. degrees Fahrenheit for bathroom 1, and 118.1 degrees Fahrenheit for bathroom #2.

Medications, First-Aid Kit & Book:

A first aid kit stored in the kitchen had been inspected which has 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 the den cabinet locked and inaccessible to clients.

Clients & Staff Files:

Applicant will be handling cash resources for clients. Cash resources locked and stored with P & I Ledger, in activity room cabinet, accessible to designated staff only. Files for clients and staff are stored and

Continued on LIC 809C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC809 (FAS) - (06/04)

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