198320333-11-30-2022-11-AS-PSCT-CLNPP2-20221130102850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320333
Report Date: 11/30/2022
Date Signed: 11/30/2022 10:28:57 AM

Document Has Been Signed on 11/30/2022 10:28 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:	HAPPY NEST		FACILITY NUMBER:	198320333
ADMINISTRATOR:	SMITH, RONNIE		FACILITY TYPE:	735
ADDRESS:	1411 W BENNETT ST		TELEPHONE:	(310) 874-3157
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 4		CENSUS: 0	DATE:	11/30/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Ronnie Smith		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 11/30/22 at 9:00am, Licensing Program Analyst (LPA) Perry Scott conducted an announced visit to this facility for the purpose of pre-licensing. LPA was greeted by applicant Ronnie Smith and the purpose of today’s pre-licensing inspection visit was explained. An application was submitted to CCLD on 08/19/22 in the initial license application for an Adult Residential Facility for ages 18 through 59 years. The applicant requested a capacity of four (4) individuals, ambulatory only. Structure: The home is a four (4) bedroom, two (2) bathroom, one-story home with a one (1) car garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The living area included a couch, coffee table, and an office chair and desk. The kitchen has a refrigerator,microwave, dishwasher, and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Residents: The facility has four (4) bedrooms for ambulatory residents. All rooms include a full- or twin-size bed, one (1) chair, one (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 on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

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: HAPPY NEST	FACILITY NUMBER: 198320333
	VISIT DATE: 11/30/2022

NARRATIVE

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Bedrooms Staff:
There will not be a live-in staff worker.
Bathrooms:
The home has two (2) bathrooms. Bathrooms are adjacent to each room. 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.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review in the living room. There are two (2) fire extinguishers located in the kitchen mounted on the wall, as well as in the hallway. A working telephone line is available in the kitchen. Emergency supplies and Personal Protective Equipment supplies are stored in the garage. 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 drawer. Food supply is adequately stored in kitchen cabinets and consists of boxed and can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space were operable.
Toxins:
All toxins are locked and stored under the kitchen sink cabinet and in the garage.

Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which include a coffee maker and toaster oven. There is one (1) refrigerator in the home. The home is equipped with central heaters and air conditioning systems.

Water Temperature:
The water temperature is 109.4 f degrees throughout the kitchen and bathrooms.
Evaluation Report Continues on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

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: HAPPY NEST	FACILITY NUMBER: 198320333
	VISIT DATE: 11/30/2022

NARRATIVE

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Medications, First-Aid Kit & Book:
A first aid kit is stored in the kitchen area under the cabinet. It was inspected and has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident’s medications will be stored in a locked location in the living room.

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 living room.

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 pools on the premises.

Fire clearance:

A Fire Clearance inspection was conducted on 09/20/22 approved for a capacity for four (4) ambulatory residents.

Component III:
LPA Scott conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with the Component III PowerPoint.

LPA observed no deficiencies that needed to be corrected during this pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been furnished to the applicant, Ronnie Smith. LPA 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.

END OF REPORT

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC809 (FAS) - (06/04)

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