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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320328
Report Date: 12/08/2023
Date Signed: 12/08/2023 04:36:27 PM

Document Has Been Signed on 12/08/2023 04:36 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:D & J ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198320328
ADMINISTRATOR:HOLMAN, JERRHONDAFACILITY TYPE:
735
ADDRESS:1609 WEST 165TH STREETTELEPHONE:
(310) 223-0215
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 6CENSUS: 4DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Shenesia GladneyTIME COMPLETED:
04:35 PM
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On 12/08/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Sheneisia Gladney. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory of which (2) may be non-ambulatory adults ages 18 through 59. The clients are South Central Los Angeles Regional Center consumers.

An audit or records between 03:03 pm - 4:30 pm of clients #1-#4 service records and staff #1-#5 personnel records revealed to be in order and complete. A review of client's P&I found to be maintained at the facility.
The facility is current on CCL annual dues.

Due to time constraints, an annual continuation inspection will need to be conducted at a later time.

An exit interview was conducted with Shenesia Gladney, and a copy of this report is provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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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