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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320382
Report Date: 12/19/2024
Date Signed: 12/19/2024 11:31:49 AM

Document Has Been Signed on 12/19/2024 11:31 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:LUNA HOMEFACILITY NUMBER:
198320382
ADMINISTRATOR/
DIRECTOR:		OKAFOR, IKEMEFUNA E.FACILITY TYPE:
735
ADDRESS:1007 W 127TH PLACETELEPHONE:
(206) 384-8455
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 4CENSUS: 3DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator - Ikemefuna E. OkaforTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 12/19/2024 around 8:30 AM, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Licensee, Chimenem Cyril. CCLD staff explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection.

This facility is licensed to serve 4 adults ages 18 to 59 years old, of which 2 may be non-ambulatory clients.

A total of 3 clients are currently residing in this facility.

The Annual Licensing Fees are current.

Facility Layout: The facility is a one-story house located in a residential street. The home consists of 4 client bedrooms, 1 full bathroom, 1 living room area, kitchen area, 1 laundry room, 1 attached garage with an office area, and 1 backyard patio area with shaded seating.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LUNA HOME
FACILITY NUMBER: 198320382
VISIT DATE: 12/19/2024
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Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises.

Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to clients in care. There is fire extinguisher in the kitchen area.

Living Room Area: There is a landline telephone, videoconferencing device (tablet), and games/activity work (i.e. board games, coloring books) for clients in the living room area. There are couches and chairs for clients to sit at.

Client Bedrooms: 4 out of 4 client bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition.

Bathrooms: Toilet, shower, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to clients.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LUNA HOME
FACILITY NUMBER: 198320382
VISIT DATE: 12/19/2024
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Medications: were inaccessible to clients in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. out of Medication Administration Records (MARs) were reviewed and they were current and up to date.

Miscellaneous: Documents are posted as mandated. The last fire and earthquake drill was conducted on 11/20/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher in the hallway next to client bedrooms.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.
3 client records were reviewed and, 3 out of 3 client records were incomplete due to being new clients. Licensee is currently working with Regional Center to complete client records.

No deficiencies are being cited based observation and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted, and a copy of this report was left with the Administrator, Ikemefuna E. Okafor.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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