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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320311
Report Date: 07/21/2023
Date Signed: 07/21/2023 03:11:42 PM


Document Has Been Signed on 07/21/2023 03:11 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:BLESSING ADULT RESIDENTIAL HOMEFACILITY NUMBER:
198320311
ADMINISTRATOR:DOTUN, PHILLIPSFACILITY TYPE:
735
ADDRESS:1963 SANTA ANA BLVD NTELEPHONE:
(310) 735-7435
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY:4CENSUS: 0DATE:
07/21/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Phillips Dotun TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Ruby Velasco and Licensing Program Manager I LPM Eva Alvarez, conducted an announced visit at the facility for the purpose of a pre-licensing evaluation on 7/21/2023. LPA and LPM met with Licensee/Administrator Phillips Dotun.

An initial application for an Adult Residential Facility (ARF) to support (4) individuals with Developmental Disabilities for ages 18 to 59 was submitted to the Community Care Licensing Adult and Senior Program on 6/10/2022. The Licensee has obtained a fire clearance approval for (4) ambulatory adult and (0) non-ambulatory adults.

The facility is a (4) bedroom, (2) full bathrooms, single story house. The client bedrooms are furnished with required, bedding, tables, chairs, dressers, closets, and sufficient lighting. The bedroom windows have security bars with quick release pulls. LPA observed a supply of linens, toiletries, and bath towels. All bathrooms have functioning commode and fixtures. The facility kitchen is equipped with appliances, dishware, and silverware. LPA observed a sufficient supply of perishable and non-perishable items. LPA observed facility refrigerator and freezer are clean and sanitary. The refrigerator and freezer meet the temperature requirements.

The home has a fully furnished living room and dining area. The laundry room is in the rear area of the kitchen and has a washer and dryer installed. The facility has a parking area for (4) vehicles. The parking is in a paved area located front of the home. There is a separate storage room located in the back of the main house. The back yard has a covered patio with table and chairs accessible to clients. LPA toured the perimeter of the home and observed all passageways clean and clear of obstructions.

LPA reviewed and inspected the facilities emergency disaster plan, infection control plan, first aid supplies, flashlights, and emergency exits that have ramps for access. The facility has two accessible fully charged fire extinguishers, as well as 5 fully functioning smoke detectors and a carbon monoxide detector. LPA observed secured storage area for chemicals, medications, and sharp objects.

LPA Velasco found no corrections are needed and will contact the Central Applications Branch with this information. An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator Phillips Dotun.

Component III:
LPA conducted Component III orientation with License/Administrator Phillips Dotun on 7/21/2023.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ruby VelascoTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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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