198320405-5-31-2024-11-AS-PSCT-D5SP5R-20240531110111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320405
Report Date: 05/31/2024
Date Signed: 05/31/2024 11:01:21 AM

Document Has Been Signed on 05/31/2024 11:01 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:	EMPOWER LIVING ADULT RESIDENTIAL FACILITY, INC		FACILITY NUMBER:	198320405
ADMINISTRATOR/ DIRECTOR:	WHITESIDE, LAQUITA		FACILITY TYPE:	735
ADDRESS:	828 E RADBARD ST		TELEPHONE:	(310) 629-5321
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 4		CENSUS: 0	DATE:	05/31/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:03 AM
MET WITH:	LaQuita Whiteside		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 05/31/24, Licensing Program Analyst (LPA) Perry Scott conducted an announced visit to this facility for the purpose of pre-licensing. LPA was greeted by LaQuita Whiteside, Administrator, and explained the purpose of today’s visit is for a pre-licensing inspection visit. An application was submitted to CCLD on 07/05/23 in the initial license application for an Adult Residential Facility age range from 18-59 years. The applicant requested a capacity of four (4) individuals, of which four (4) may be ambulatory clients. Structure: The home is a four (4) bedroom, two (2) bathroom, two-story home with a one (1) car garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Client Bedrooms: The facility has four (4) bedrooms approved for ambulatory clients only. All rooms include a Queen-size bed, one (1) chair, one (1) nightstand, and 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 continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EMPOWER LIVING ADULT RESIDENTIAL FACILITY, INC	FACILITY NUMBER: 198320405
	VISIT DATE: 05/31/2024

NARRATIVE

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Staff Bedrooms:
There will not be a live-in staff.

Bathrooms:
The home has two (2) bathrooms. All bathrooms have a working toilet, washbasin, and non-skid mats. All bathrooms are located near client bedrooms. There are night-lights in the hallways outside non-private bathrooms. Water temperature measured 106.5 degrees Fahrenheit.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linens is stored in the linen closet.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers, exit plan and menu are posted and readily available for review throughout the home. There are two (2) fire extinguishers, the first is in the kitchen and the other is located upstairs next to the bathroom mounted on the wall. A telephone line is available in the dining room and office area. Emergency supplies and Personal Protective Equipment supplies are stored in a closet at the entrance of the facility. The applicant submitted a Mitigation Plan on 06/10/23.

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 the utility closet along with the first aid and medication for clients. Food supply is adequately stored in kitchen cabinets and consists of boxed and can goods. The kitchen counters also had small appliances.

Smoke Detectors:

Smoke and carbon monoxide detectors were throughout the interior space. Hardwired smoke detectors in all four (4) bedrooms and hallways. Carbon monoxide is combined with smoke detectors. There will be no firearms or ammunition stored at the facility.

Evaluation Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

Page: 2 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EMPOWER LIVING ADULT RESIDENTIAL FACILITY, INC	FACILITY NUMBER: 198320405
	VISIT DATE: 05/31/2024

NARRATIVE

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

Stove burners, oven, microwave, washer, and dryer are working. There is one (1) refrigerator in the home. The home is equipped with central heaters and air conditioning systems.

Water Temperature:
The water temperature measured 106.3 degrees F. in the kitchen and 106.5 degrees F. in the bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the medication cabinet. It was inspected and has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The client’s medications will be stored in the same medication cabinet and is locked and inaccessible to clients. The facility also has emergency and earthquake food supply kits in the event of a disaster, which includes emergency backpacks for clients.

Client & Staff Files:
The applicant is handling the cash resources for the clients and has the proper notebooks and lock boxes to store and record the transactions for each client. 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 and are stored in the living room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pools on the premises.

Evaluation Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EMPOWER LIVING ADULT RESIDENTIAL FACILITY, INC	FACILITY NUMBER: 198320405
	VISIT DATE: 05/31/2024

NARRATIVE

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Fire clearance:
A Fire Clearance inspection was conducted on 09/13/23 and approved for a capacity for four (4) ambulatory clients only.

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

LPA observed no deficiencies that needed to be corrected during this pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been furnished to the administrator, LaQuita Whiteside.

LPA Scott 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: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

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