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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320331
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:02:44 AM

Document Has Been Signed on 10/13/2022 11:02 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:TML ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198320331
ADMINISTRATOR:GLADNEY, SHENESIAFACILITY TYPE:
735
ADDRESS:812 S. BULLIS ROADTELEPHONE:
(562) 225-1038
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY: 4CENSUS: DATE:
10/13/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Jerrhonda HolmanTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs, Martessa conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to CCLD on 7/29/22, for a license Adult Residential Facility to serve Developmentally Disabled Adults for ages 18 to 59 years. The requested capacity is for 4 clients, 2 non-ambulatory.

Facility is a 4-bedroom, 2-bathroom, single story house with a 2-car attached garage. Bedroom 4 will be used as an office. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a back yard with a covered patio for shade. The patio contained 1 table and 4 chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe any hazards. Bedrooms Residents: Bedroom #1, #2 and #3 each have one bed, one chair, one-night stand, one lamp in addition to overhead lighting. There is one dresser with two drawers in Bedrooms #1, #2 and #3 which comply with the requirement of 8 cubic feet of space. There were no designated staff bedrooms observed. Bathrooms: Bathrooms #1 and #2 have 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. Adequate supply of linen stored in hall closet.
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. Smoke Detectors: 4 smoke detectors are battery and electric operated & working. Carbon monoxide detector located and mounted in the hallway is operational. Appliances: Stove burners, oven, microwave, washer, and dryer working.

LIC 809-C is on the next page.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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: TML ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320331
VISIT DATE: 10/13/2022
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There are 2 refrigerators 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 47 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: Locked/stored in the storage room located in the kitchen. Water Temperatures: Tested at 119 and 118 Fahrenheit. 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 kitchen cabinet adjacent the refrigerator, 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 $4,000.00. 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: approved on 8/31/22 for 2 ambulatory and 2 non-ambulatory clients 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: Waived because the applicant has other licensed adult residential facilities.

An exit interview was conducted and a copy of the report was furnished to the applicant. LPA Brown will submit a copy of this facility evaluation report to the Central Applications Unit (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: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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