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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320352
Report Date: 02/28/2025
Date Signed: 02/28/2025 11:49:32 AM

Document Has Been Signed on 02/28/2025 11:49 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MOORE FAMILY HOME, LLCFACILITY NUMBER:
198320352
ADMINISTRATOR/
DIRECTOR:		MOORE, JAMESFACILITY TYPE:
735
ADDRESS:238 W 231ST STREETTELEPHONE:
(310) 835-3082
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Jacquelin "Jackie" Medina, DSPTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 02/28/2025 at 9:10am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Jacquelin Medina, DSP and the purpose of today’s visit was explained. The facility is licensed for (4) ambulatory adults ages 18-59 years of ages. Currently, the home has (4) clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facility annual fees $0 (payment of $454.00 made on 01/29/2025 at 4:07pm). The last fire drill was conducted 02/12/2025 at 5pm. The liability insurance is with American Southern Home Ins. Fund with effective date 02/21/2025 - policy expiration 02/21/2026 and the policy # G8A6GL000005302.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: three (3) clients' rooms, two (2) common bathrooms, (2) staff rooms, a living area, a dining area, a kitchen,a den,a backyard with 2 locked sheds and a covered jacuzzi, a garage with a washer, a dryer and two additional refrigerators and an outside patio area (in the front of the home and in the backyard).



Between the hours 9:30 am - 10:30am of LPA conducted a records review of (4) client records, (4) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

Report continues on LIC 809-C.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: MOORE FAMILY HOME, LLC
FACILITY NUMBER: 198320352
VISIT DATE: 02/28/2025
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At 9:14 am LPA and Jacquelin Medina toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F ( Bathroom #1: 119.7F and Kitchen: 112.3F).

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with Jacquelin "Jackie" Medina, DSP

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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