198320339-10-26-2022-11-AS-ASOO-CKKV2Z-20221026160357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320339
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:05:34 PM

Document Has Been Signed on 10/26/2022 04:05 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	PRIORITY ONE ADULT RESIDENTIAL		FACILITY NUMBER:	198320339
ADMINISTRATOR:	TALLEY, CHANDRA		FACILITY TYPE:	735
ADDRESS:	13512 S. ARDATH AVENUE		TELEPHONE:	(310) 354-3927
CITY:	GARDENA	STATE: CA	ZIP CODE:	90249
CAPACITY: 4		CENSUS: 4	DATE:	10/26/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Dennis Cooper, Supervisor		TIME COMPLETED:	03:30 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	Licensing Program Analysts (LPA) Ana Soto conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on 10/10/2022 for a change of ownership license for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18-59 years. The requested capacity is for (4) clients ambulatory, (0) non-ambulatory, and (0) bedridden. Structure: Facility is a three (4) bedroom, one (2) full bathroom, single story house with small covered front porch, covered back patio, and small side porch off the kitchen, an attached 2 car garage. The facility is a brown wood/ stucco structure with large front yard and small wide backyard. Front yard landscape is in good condition. Covered back patio has 2 tables, chairs. Signal System: No signal system in facility. Bedroom Residents: There shall be no more than two clients per bedrooms. bedrooms are designated client bedrooms properly equipped with regulation guidelines of two beds, two chairs, two night-stands, two lamps and overhead lighting. Presently, 4 bedrooms are occupied by 4 clients. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 1st - full bathroom located in Bedroom #2. 2nd bathroom is located between bedroom #2 and Bedroom #3 both bathrooms have a working toilet and wash basin. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in hallway closets. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in kitchen bulletin board. Facility has a land line telephone located in the kitchen area and living room. 1 Fire extinguisher, one 1A10BC mounted in kitchen wall next to the exit door, which is labeled, it is tagged with current annual checks.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PRIORITY ONE ADULT RESIDENTIAL	FACILITY NUMBER: 198320339
	VISIT DATE: 10/26/2022

NARRATIVE

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Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen and consists of the following: 2-day perishables, and 7-week non-perishables. Smoke Detectors: There are 6 hard wired smoke detectors, and 1 battery operated carbon monoxide detector located living room wall and are operational. Appliances: Stove burners, oven, microwave, and washer/dryer are in working condition. There is one refrigerator in the home and a freezer in the garage. The residence is equipped with window air conditioning. Toxins: Cleaning supplies, and toxins are stored in two locations: locked cabinet in the kitchen and locked cabinet in garage. Water Temperature: Water was tested in the kitchen sink, 119.1 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in dining room with lock. A 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 with medication in the hallway closet, available for staff use but inaccessible to clients. Clients & Staff Files: Files are located in the kitchen office space in locked desk drawer. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. . Fire Clearance: Fire clearance does not indicate any delayed egress or any locked perimeter. Component III: Conducted at the Pre-Licensing visit.

During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, client private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder and required postings throughout the facility. Visitor designated area, facility has internet & computers for clients to use, clients temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days.

The facility has no corrections.

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

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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