198320332-11-9-2022-11-AS-PSCT-CKZRJ8-20221109120331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320332
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:03:41 PM

Document Has Been Signed on 11/09/2022 12:03 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:	TRUE DESTINY		FACILITY NUMBER:	198320332
ADMINISTRATOR:	REED, SHEILA		FACILITY TYPE:	735
ADDRESS:	10613 S 8TH AVE.		TELEPHONE:	(310) 704-4476
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90303
CAPACITY: 4		CENSUS: 0	DATE:	11/09/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Sheila Reed		TIME COMPLETED:	12:45 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 11/09/22, Licensing Program Analyst (LPA) Perry Scott conducted an announced visit to this home. LPA was greeted by applicant Sheila Reed and LPA explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 08/08/22 in the initial license application for an Adult Residential Facility ages 18-59 years old. The applicant requested a capacity of four (4) individuals, of which all four (4) will be ambulatory. Structure: The home is a three (3) bedroom, two and ½ bathroom, one-story home with a garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The living room area has a fireplace not in use. The living area included couches, recliners, and a table. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Residents: The facility has three (3) bedrooms, two will be used for residents, the other is being used as an office now. There are two bedrooms with two beds in each for ambulatory residents. All rooms include two 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. One room had two nightstands. Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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: TRUE DESTINY	FACILITY NUMBER: 198320332
	VISIT DATE: 11/09/2022

NARRATIVE

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

Bathrooms:
The home has two and ½ 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 closet inside the bedrooms.

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 but is not working. Emergency supplies and Personal Protective Equipment supplies are stored in the cabinet in the kitchen. The applicant has submitted an Infection Control 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 drawer. Food supply is adequately stored in kitchen cabinets and consists of the can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Carbon monoxide is combined with smoke detectors.
Toxins:
All toxins are stored under the kitchen sink but needs a lock.
Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: TRUE DESTINY	FACILITY NUMBER: 198320332
	VISIT DATE: 11/09/2022

NARRATIVE

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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 central heaters and air conditioning systems.

Water Temperature:
The water temperature measured 75.5 degrees throughout the kitchen and bathrooms. They need to measure between 105-120 F to be complying.

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. Currently there is no lock on the cabinet.

Resident & Staff Files:
The applicant will be handling the cash resources for residents. Records of staff and residents will be stored in a metal cabinet in the dining area. The administrator is waiting for the cabinet to be delivered.

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 10/14/22 approved for a capacity of four (4) ambulatory residents.

Component III:
LPA did not complete component III at this time because the applicant has a few corrections that need to be made first.
Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: TRUE DESTINY	FACILITY NUMBER: 198320332
	VISIT DATE: 11/09/2022

NARRATIVE

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The deficiencies were as follows:

LPA observed that there is not a lock on the designated medication cabinet.
LPA observed that there is not a lock on the area under the sink where the toxins will be kept.
LPA observed that there is not a cabinet for the residents/staff files.
LPA observed that the water temperature in the facility is too low. It measures at 75.5 degrees F. It should be between 105-120 F.
LPA observed that there needs to be a lock on the supply cabinet in the laundry room.
LPA observed that the table in the back yard needs to be hauled away.
LPA observed there were no night lights in the hallway but there was overhead lighting accessible to clients as there leaving their bedroom.
LPA observed that there is no shower curtain or rod in one of the bathrooms.
LPA observed that the landline phone in the living room is not working.

Before a license can be issued the applicant will need to make corrections to the aforementioned items.
LPA will return on 11/21/22 to evaluate the corrections.

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

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC809 (FAS) - (06/04)

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