198320328-11-22-2022-11-AS-PSCT-CLEPJQ-20221122102155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320328
Report Date: 11/22/2022
Date Signed: 11/22/2022 10:22:23 AM

Document Has Been Signed on 11/22/2022 10:22 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	D & J ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198320328
ADMINISTRATOR:	HOLMAN, JERRHONDA		FACILITY TYPE:	735
ADDRESS:	1609 WEST 165TH STREET		TELEPHONE:	(310) 223-0215
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 6		CENSUS: 4	DATE:	11/22/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jerrhonda Holman		TIME COMPLETED:	11:00 AM

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 11/22/22, Licensing Program Analyst (LPA) Perry Scott conducted an announced visit to this home. LPA was greeted by applicant Jerrhonda Holman and LPA explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 07/29/22 in the initial license application for an Adult Residential Facility ages 18-59 years old. The applicant requested a capacity of six (6) individuals, of which four (4) will be ambulatory and two (2) will be non-ambulatory. Structure: The home is a four (4) bedroom, two (2) bathroom, one-story home with a garage situated in a residential neighborhood. The home includes a living room, kitchen, and laundry area. The living area included couches, love seat, and a table. The kitchen has a refrigerator, microwave, and a stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Residents: The facility has four (4) bedrooms, three will be used for residents, the other is being used as an office now. There are two bedrooms with one bed in each, and one bedroom with two beds. All rooms include twin-size beds one (1) chair, (1) nightstand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: D & J ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198320328
	VISIT DATE: 11/22/2022

NARRATIVE

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Bedrooms Staff:
There is no bedroom designated for live-in staff.

Bathrooms:
The home has two bathrooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall storage area.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There is one (1) fire extinguisher located in the kitchen mounted on the wall. A telephone line is available in the living room. Emergency supplies and Personal Protective Equipment supplies are stored in the office. The applicant has submitted a mitigation plan.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet. Food supply is adequately stored in kitchen cabinets and consists of can and other dry goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space are operable.

Toxins:
All toxins are stored under the kitchen sink.

Stove burners, oven, microwave, washer, and dryer are working. There is one (1) refrigerator in the home. The refrigerator measured a temperature of at least 45 degrees Fahrenheit for appropriate food storage. The home is equipped with heaters and air conditioning systems in each room.
Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: D & J ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198320328
	VISIT DATE: 11/22/2022

NARRATIVE

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Water Temperature:
The water temperature measured 109.5 degrees throughout the kitchen and bathrooms.
Medications, First-Aid Kit & Book:
A first aid kit is stored in the medication cabinet inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The client's medications will be stored in the same medication cabinet locked in the kitchen area and inaccessible.
Resident & Staff Files:
The applicant will be handling the cash resources for residents. Records of staff and residents will be stored in a locked cabinet in the hallway and in the office.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the resident's use all stored in the living room.
Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.
Fire clearance:
A Fire Clearance inspection was conducted on 08/31/2022 approved for a capacity of six (6) residents; Four (4) ambulatory and two (2) non-ambulatories.
Component III:
LPA and the applicant completed component III which gives an overview of what to expect while running the facility.

During the pre-licensing visit LPA Perry Scott did not observe any deficiencies.

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

LPA Perry Scott 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: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

LIC809 (FAS) - (06/04)

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