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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320293
Report Date: 01/23/2023
Date Signed: 04/12/2023 04:18:57 PM

Document Has Been Signed on 04/12/2023 04:18 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:LEISURE LIVING ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198320293
ADMINISTRATOR:ANTAR, ALIFACILITY TYPE:
735
ADDRESS:14012 SOUTH KALSMAN AVETELEPHONE:
(323) 239-7487
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 4CENSUS: 0DATE:
01/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tina Duff-LicenseeTIME COMPLETED:
04:30 PM
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On 4/12/23, Licensing Program Analyst (LPA), Martessa Brown conducted a continuation visit to the facility for purpose of a pre-licensing evaluation. LPA met with Tina Duff-Licensee. An application was submitted to CCLD on 4/18/22 for Initial license for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18 to 59 years. The requested capacity is for 2 ambulatory clients.

Facility is 2 bedrooms and 1 bathroom, single story house with a garage. The client bedrooms are spacious and will easily accommodate the client's furnishings. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPAs did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: All Bedrooms are for 2 ambulatory clients. Bedroom #1-2 each have one bed, one chair, one-night stand, one lamp in addition to overhead lighting. There is one dresser in each bedrooms #1-2 which comply with the requirement of 8 cubic feet of space. There were no designated staff bedrooms observed. Bathroom: Bathrooms #1 has a working toilet, wash basins and showers. LPA observed adequate lighting in hallway leading to bathrooms #2. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads.

Emergency Phone Numbers, Exit Plan & Menu: The telephone system has a land line. Emergency Disaster Plan and "See something, Say something Let Us Know" posted & readily available for review on the wall between the living room and kitchen. Menu available for review located in a locked kitchen cabinet opposite the refrigerator. Fire Extinguisher mounted on the kitchen wall. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet located in the kitchen area. Food supply inadequate but applicant will increase inventory; stored in kitchen refrigerator and cabinets and consists of the following: A variety of Fresh and Canned fruit, vegetable and meat food items.
809-C is on the next page.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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 2
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: LEISURE LIVING ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320293
VISIT DATE: 01/23/2023
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Smoke Detectors: smoke detectors and carbon monoxide were working. Appliances: Stove burners, oven, microwave, washer and dryer working. There is 1 refrigerator in the home, one in the kitchen and one in the garage for additional food storage. Refrigerator in the kitchen has a measured temperature of at least 53 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central air and heat. Toxins: Locked/stored in the storage room located in the cabinet hallway. Water Temperature: Tested at 115.5 F degrees. Medications, First-Aid Kit & Book: Medication administration records and first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in locked, available for staff use but inaccessible to clients. Clients & Staff Files: Applicant will be handling cash resources of clients and has a surety bond for $3,000.00. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked in staff office and the section has been inspected along with the available records present.

Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. Activity board is posted on the wall between the kitchen and the living room. Pool/Jacuzzi & Pets: LPA did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 8/17/22 for 2 Ambulatory with no special instructions. LPA did not observe delayed egress, chain locks or dead bolts on exits. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Component III: Conducted at the Pre-Licensing visit on 4/12/23 at Leisure living Adult Residential Facility, information provided about how to operate the facility within substantial compliance.
During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA, Martessa Brown by 4/19/23. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date.
*** Licensee/Administrator will have the following fixed. ****LPA observed in bedroom #1 left window was unable to stay open and locks for cleaning supplies. Administrator will send LPA pictures by 4/19/23.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA Martessa Brown will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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