198320390-8-2-2023-11-AS-LVIS-CUBTTH-20230802150042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320390
Report Date: 08/02/2023
Date Signed: 08/02/2023 03:00:47 PM

Document Has Been Signed on 08/02/2023 03:00 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:	PERSON CENTERED OPTIONS II		FACILITY NUMBER:	198320390
ADMINISTRATOR:	THOMPSON, TIKI		FACILITY TYPE:	735
ADDRESS:	1402 E. WASHINGTON STREET		TELEPHONE:	(909) 904-2913
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90805
CAPACITY: 3		CENSUS: 2	DATE:	08/02/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:59 AM
MET WITH:	Administrator Tiki Thompson		TIME COMPLETED:	02:45 PM

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On 08/02/2023, Licensing Program Analyst (LPA) Lizeth Villegas conducted an announced visit to this home. LPA was greeted by Tiki Thompson and Verretta Boatner and explained the purpose of today’s pre-licensing (CHOW) inspection visit.

An application was submitted to CCLD on 06/08/2023 for CHOW of an Adult Residential Facility The applicant requested a capacity of three (3) ambulatory of which one (1) may be non-ambulatory adults ages 18-59. Residents are linked to Harbor regional center.

Structure:
The facility is a one-story house located in a residential neighborhood and consists of four (4) bedrooms, two (2) bathrooms, one (1) bathroom is for staff only, two (2) car garage, living room, family room, staff work area, dining area,laundry room and kitchen. The facility is clean, sanitary, and in good repair. Protective devices are in place to include non-slip material on rugs. All window screens are clean and in good repair.

Bedrooms (Residents):

The facility has three (3) bedrooms ambulatory clients and one (1) bedroom for a non-ambulatory resident. All rooms include required furniture. No client bedroom is a passageway to another room, bath, or toilet.

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 closet adjacent to the client’s bedrooms and bathroom.

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 are (2) fire extinguisher located in the family room and in the kitchen area.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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: PERSON CENTERED OPTIONS II	FACILITY NUMBER: 198320390
	VISIT DATE: 08/02/2023

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A telephone line is available in the kitchen. Emergency supplies are stored in the garage.

Food Service:
All kitchen areas are clean and free of litter, rodents, vermin, and insects. The refrigerator and freezer are clean and of adequate size. The freezer is maintained at 0 degrees Fahrenheit and the refrigerator is below the required maximum of 40 degrees Fahrenheit. A two (2) day supply of perishable foods and a seven (7) day supply of non-perishable food were observed. All equipment, appliances, dishes, and utensils are clean and well maintained. The water temperature is between 105-120 degrees F.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space are operable.

Toxins:
All toxins are locked and stored under the kitchen sink cabinet. A first aid kit is complete and stored in a locked cabinet .The client's medications will be stored in a locked cabinet in the dinning 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 living room.

Fire clearance:
A Fire Clearance inspection was conducted on 05/17/2023 with approval for a capacity of four (4) of which three (3) ambulatory and one (1) is non-ambulatory.

Component III:
The applicant completed the Comp III training during today’s visit.

During today’s visit no discrepancies were cited.

Exit interview conducted with Tiki Thompson, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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