198320413-12-11-2023-11-AS-WGIS-CYERPT-20231211121227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320413
Report Date: 12/11/2023
Date Signed: 12/11/2023 12:12:39 PM

Document Has Been Signed on 12/11/2023 12:12 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CLEAR BEHAVIORAL HEALTH		FACILITY NUMBER:	198320413
ADMINISTRATOR:	ARTIAGA, CAITLIN		FACILITY TYPE:	772
ADDRESS:	18616 MANHATTAN PL		TELEPHONE:	(877) 799-1985
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY: 6		CENSUS: 0	DATE:	12/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kristen Uppercue		TIME COMPLETED:	12:30 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 12/11/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an announced Pre-Licensing Visit at the facility listed above. LPA met with Executive Assistant, Kristen Uppercue, and explained the purpose of today’s visit. An application was submitted to CCLD on 08/02/23 for an Adult Residential Facility. The facility has been approved with a fire clearance to house 6 ambulatory residents ages 18-59 on 09/14/23. There are no clients residing in the facility. Physical Plant/Structure LPA toured the facility with Executive Assistant. The facility is a single-story home in a residential neighborhood. It consists of four (4) bedrooms, three (3) bathrooms, nurses office, staff room, therapy office, living room, dining room, kitchen and attached garage. The front and back yard are landscaped and well kept. LPA observed a shaded seating area in the back yard. All walkways outside of the facility were observed clean, clear, and free of debris, obstructions, and hazards. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected the four (4) bedrooms and found them to be clean and in good repair. Bedrooms 1 and 2 are single occupancy and bedrooms 3 and 4 are set up for a double occupancy. All bedrooms were observed with the required furnishings including a bed(s), dresser, nightstand(s), chair(s), and ample storage space for personal belongings. All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens, in the hall cabinet, in good repair. All bedrooms were observed with ample lighting. Bathroom LPA inspected all bathrooms and found them to clean and operational. There are three bathrooms, bathroom 1 has a shower, toilet and wash basin, bathroom 2 has a toilet and wash basin, and bathroom 3 is a private bathroom in bedroom 4. All showers were observed clean and with non-skid mats. LPA observed an ample supply of personal hygiene supplies, towels, hand towels and wash clothes in a cabinet in the hallway.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CLEAR BEHAVIORAL HEALTH	FACILITY NUMBER: 198320413
	VISIT DATE: 12/11/2023

NARRATIVE

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Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed an ample supply of cookware, dining ware, and cutleries in good repair. All appliances were observed in good repair. LPA observed a 3-day supply of perishable foods and a 5-day supply of nonperishable foods stored properly. LPA observed a sample menu posted on a corkboard near the kitchen. LPA observed sharps secured in a locked closet in the hallway. LPA observed all cleaning supplies secured in a locked closet in the hallway.

Common Rooms LPA inspected all common rooms and found them to be clean and appropriately furnished. The dining room has a large rectangular table with six chairs to accommodate clients. The living room was observed with two (2) large couches to accommodate all clients. LPA observed a fireplace screened and inaccessible to clients. LPA observed games, activities, yoga equipment, and reading material stored in the entertainment center accessible to clients. The facility has internet available for clients use. LPA observed a sample activity schedule posed on a corkboard near the living room. The facility was maintained at a comfortable temperature. LPA observed all hallways and walkways in the facility to be clean, clear, and free of hazards and obstructions.

Safety The facility was granted fire clearance for 6 ambulatory residents on 09/14/23. LPA observed 5 fire extinguishers mounted throughout the facility, serviced on 09/01/23. The smoke detectors and carbon monoxide detectors were tested and are operable. All exits were clearly marked, and emergency exit sketch are posted in every room. LPA observed emergency numbers posted and required CCL signs posted in the facility. The facility has a telephone in the nurse’s office that is for emergencies and client use. All gates on the side of the home open easily to exit in an emergency.

Medications Centrally Stored Medications will to be stored in the locked nurse’s office secured in a locked cabinet or locked refrigerator. Medications dispensing with be documented on an eMAR. LPA inspected the First Aid Kit and found it contained the required item and a manual.

Files Client files will be secured in a locked filing cabinet in the locked nurse’s office. Staff files will be secured in a locked filing cabinet in the locked staff room.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CLEAR BEHAVIORAL HEALTH	FACILITY NUMBER: 198320413
	VISIT DATE: 12/11/2023

NARRATIVE

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Component III was reviewed and discussed with Executive Assistant.

During the Pre-Licensing inspection the following items were observed. The following item must be corrected, and proof of correction shall be submitted to CCLD office to the attention of LPA Gibbs by 12/18/23. If additional time is required to complete noted item to correct, then the applicant will request an extension in writing prior to the due date.

1. An Ombudsman sign posted, and visible for clients.
2. A video of the water temperature being taken. There is an issue with the gas and the gas company is not available till 12/15/23.
3. A video of the stove burners operating. There was an issue with the gas and the gas company is not available till 12/15/23.

An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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