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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320291
Report Date: 03/08/2024
Date Signed: 03/08/2024 11:01:07 AM

Document Has Been Signed on 03/08/2024 11:01 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:AMARYLLIS TRANSITION HOUSING LLCFACILITY NUMBER:
198320291
ADMINISTRATOR:WALLACE, CLEMENTINEFACILITY TYPE:
735
ADDRESS:2229 E 121 STREETTELEPHONE:
(424) 757-7480
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 2CENSUS: 0DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee - WALLACE, CLEMENTINETIME COMPLETED:
11:30 AM
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On 03/08/2024 at around 8:00 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator Clementine Wallace. LPA explained the purpose of the visit and was accompanied by Licensee inside and outside the facility during this inspection.

This facility is licensed to serve 2 ambulatory adults ages 18 – 59 years.

A total of 0 clients are currently residing in this facility.

The Annual Licensing Fees are current.

The facility is a one-story house located in a residential street. The home consists of 1 client bedroom, 2 staff bedrooms, 2 bathrooms, 1 living room, 1 dining room, 1 kitchen, 1 lounge, 1 detached garage, and 1 backyard patio area with shaded seating.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMARYLLIS TRANSITION HOUSING LLC
FACILITY NUMBER: 198320291
VISIT DATE: 03/08/2024
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LPA toured the facility and observed no bodies of water around the facility. The patio furniture is under a shaded area and accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. The kitchen area has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There are 2 fire extinguishers in the facility.

The client’s bedroom was checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly.

1 staff record was reviewed, 1 out of 1 staff record had current First Aid Certificate and required Criminal Record Clearance.

No deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted and a copy of this report left with the Licensee.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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