198320313-1-25-2023-11-AS-FSHY-CNET6K-20230125132717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320313
Report Date: 01/25/2023
Date Signed: 01/25/2023 01:27:46 PM

Document Has Been Signed on 01/25/2023 01:27 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:	RISING SUN RESIDENTIAL HOME		FACILITY NUMBER:	198320313
ADMINISTRATOR:	DUNCAN, JAMILAH		FACILITY TYPE:	735
ADDRESS:	2021 W 65TH PL		TELEPHONE:	(562) 394-6014
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY: 6		CENSUS: 0	DATE:	01/25/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jamilah Duncan		TIME COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/25/2023 Licensing Program Analyst (LPM) Stephanie Cifuentes and LPA Felisa Shirley conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Today’s pre-licensing evaluation was conducted with applicant Jamilah Duncan. LPA and LPM explained the purpose of the visit and where allowed into the facility. On 9/26/2022 an initial application was received for an Adult Residential Facility to serve Developmentally Disabled Adults from ages 18 to 59 years. The requested capacity is for 6 clients, 6 ambulatory. Facility has a fire clearance for 6 ambulatory clients only. Structure: Facility is a 3-client bedroom, 1 staff room, 1 1/2- bathroom, two-story house with a 1 car attached garage and an outdoor shaded area in the back yard. The client bedrooms are spacious and easily accommodate the client's furnishings. There is a back yard which contains a table and 6 chairs as well as an umbrella for shade. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA and LPM 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 three client bedrooms have two beds, two chairs, overhead lighting, closets and dressers. All drawers comply with the requirement of 8 cubic feet of space. There is one designated staff room upstairs on the second floor. Bathrooms: Bathrooms has working toilets, wash basins and shower/bathtub. Continued on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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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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: RISING SUN RESIDENTIAL HOME	FACILITY NUMBER: 198320313
	VISIT DATE: 01/25/2023

NARRATIVE

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Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillow cases, hand towels, bath towels and wash clothes where observed stored in each bedroom.

Emergency Phone Numbers, Exit Plan & Menu: The telephone is a cell phone which was called by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on hallway wall. Three fully charged fire extinguishers were found in the facility, one mounted on kitchen wall, one by washer and dryer and another in staff room.

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. Food supply was adequately stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items.

Smoke Detectors: 6 interconnected and hard wired dual smoke/carbon monoxide detectors are present in the facility. All were tested and are fully operational.

Appliances: Oven, microwave, dish washer, washer, and dryer are operational. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage. The residence is equipped with central heat and air.

Toxins: Locked/stored in garage.

Medications, First-Aid Kit & Book: Area for medication storage and records was inspected, they are kept in separate locked file cabinet. First aid kit, located in a locked cupboard off of the kitchen area, was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to clients.

Clients & Staff Files: Applicant will be handling clients cash resources, which will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a file cabinet in dining room, section has been inspected along with the available records present.

Continued on 812-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: RISING SUN RESIDENTIAL HOME	FACILITY NUMBER: 198320313
	VISIT DATE: 01/25/2023

NARRATIVE

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Reading Material, Games, Equipment & Materials: The facility has board games, puzzles, DVD’s, books, and other recreational materials for the client's use.

Pool/Jacuzzi & Pets: LPA's did not observe any pet or bodies of water at the facility.

Fire clearance: Fire Clearance was approved on 9/26/2022 for 6 ambulatory clients with no special instructions. 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 1/25/2023 at Rising Sun Residential Home, information provided about how to operate the facility within substantial compliance.

The following corrections need to be completed before licensure:
1. Window screen needed for bedroom 1.

Proof of correction requested for 1/27/2023

An exit interview was conducted, and a copy of this report has been furnished to the applicant.

Accordingly, LPA 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 the applicant.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

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