198320352-2-8-2023-11-AS-EDAT-CNV2ZG-20230208165020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320352
Report Date: 02/08/2023
Date Signed: 02/08/2023 04:50:50 PM

Document Has Been Signed on 02/08/2023 04:50 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:	MOORE FAMILY HOME, LLC		FACILITY NUMBER:	198320352
ADMINISTRATOR:	MOORE, JAMES		FACILITY TYPE:	735
ADDRESS:	238 W 231ST STREET		TELEPHONE:	(310) 835-3082
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 4		CENSUS: 4	DATE:	02/08/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:34 PM
MET WITH:	Jill & James Moore		TIME COMPLETED:	03:17 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 02/08/23, Licensing Program Analysts (LPAs) Ernand Dabuet, Lizeth Villegas and Licensing Program Manager (LPM) Janae Hammond conducted a visit to this home. The team was greeted by applicant Jill Moore and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 10/25/22. In the initial license application for a Residential Facility for Adults, ages ranging from 18-59 years old. The applicant requested for a capacity of four (4) individuals, of which four (4) ambulatory, zero (0) non-ambulatory, and zero (0) bedridden. Structure: The home is a five (5) bedroom, three (3) bathroom, two story home with a garage situated in a residential neighborhood. The home includes a living, a dining, a kitchen, a den, and laundry area. The living room area has a covered fireplace. The living area included sofas and a table. The kitchen has tile counter tops with a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Clients: The facility had three (3) bedrooms for clients on the lower floor. The three (3) bedrooms are for non-ambulatory clients. All rooms include (1) a full-size bed, one (1) chair, one (1) night stand, 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

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MOORE FAMILY HOME, LLC	FACILITY NUMBER: 198320352
	VISIT DATE: 02/08/2023

NARRATIVE

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Bedrooms Staff:
There are two (2) bedrooms for staff for live-in staff on the upper floor.

Bathrooms:
The home has two (2) bathrooms. Bathroom #1 is accessible to bedrooms #1 and #2 through a hallway. Bathroom #2 is accessible to bedroom #3. 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 adjacent to the client’s 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 kitchen and bedroom #2. Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant submitted a Mitigation Plan and Residential 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. Hardwired smoke detectors in all bedrooms and hallways. Carbon monoxide a total of two (2) are located in the hallway and kitchen.

Toxins:
All toxins are locked and stored under the in the garage.

Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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: MOORE FAMILY HOME, LLC	FACILITY NUMBER: 198320352
	VISIT DATE: 02/08/2023

NARRATIVE

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Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which include a toaster, and a blender. There is one (1) refrigerator in the home. The refrigerator measured a temperature of at least 45 degrees Fahrenheit for appropriate food storage. A second refrigerator is located in the garage for backup food supplies and medications that are required to be refrigerated. The home is equipped with wall mounted heaters and air conditioning systems.

Water Temperature:
The water temperature is 109.0 degrees throughout the kitchen and bathrooms. A comfortable room temperature of 71 degrees F.

Medications, First-Aid Kit & Book:
A first aid kit is stored in kitchen cabinet inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to clients. The client's medications will be stored in the same medication cabinet locked in the dining area and inaccessible to clients.

Clients & Staff Files:
The applicant is handling the cash resources of clients and will be stored in a locked safely inside a locked cabinet in the office area. Records of staff and clients will be stored in a cabinet in the office area.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the client's use all stored in the activity room.

Pool/Jacuzzi & Pets:
There is no pool in the fenced area.

Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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: MOORE FAMILY HOME, LLC	FACILITY NUMBER: 198320352
	VISIT DATE: 02/08/2023

NARRATIVE

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Fire clearance:
A Fire Clearance inspection was conducted on 01/04/23 with approval for a capacity for zero (0) non-ambulatory, four (4) for ambulatory, and zero (0) for bedridden.

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

LPA observed no corrections during this pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been furnished to the applicant, Jill Moore. LPA Dabuet 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: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC809 (FAS) - (06/04)

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