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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320331
Report Date: 10/04/2023
Date Signed: 10/05/2023 08:25:10 AM

Document Has Been Signed on 10/05/2023 08:25 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:TML ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198320331
ADMINISTRATOR:HOLMAN, JERRHONDAFACILITY TYPE:
735
ADDRESS:812 S. BULLIS ROADTELEPHONE:
(562) 225-1038
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY: 4CENSUS: 3DATE:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Director Jerrhonda HolmanTIME COMPLETED:
12:00 PM
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On 10/04/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Director Jerrhonda Holman as the purpose of today’s visit was explained. The facility is licensed to serve Developmentally Disabled Adults for ages 18 to 59 years. The requested capacity is for 4 clients of which 2 may be non-ambulatory. Clients are linked to the South Central Los Angeles Regional Center.

The single story facility consist of the following: a 2-car attached garage, 3 Bedrooms, 2 bathrooms which 1 is a private bathroom, 1 office, a laundry area, a linen closet, living room, dining area, kitchen, a stocked pantry and a back yard with a covered patio for shade.

LPA conducted a records review of 2 staff records, 1 client record, 1 and 1 Medication Administration Record, LPA did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 08/02/23, 1 fire extinguishers fully charged, carbon monoxide detectors observed, smoke detectors are operational. Landline and internet service was observed.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TML ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320331
VISIT DATE: 10/04/2023
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During today’s visit no discrepancies were cited.

Exit interview conducted with Director Jerrhonda Holman, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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