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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320413
Report Date: 11/25/2024
Date Signed: 11/25/2024 12:51:33 PM

Document Has Been Signed on 11/25/2024 12:51 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CLEAR BEHAVIORAL HEALTHFACILITY NUMBER:
198320413
ADMINISTRATOR/
DIRECTOR:
LINDSEY RAE ACKERMANFACILITY TYPE:
772
ADDRESS:18616 MANHATTAN PLTELEPHONE:
(877) 799-1985
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 4DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:52 AM
MET WITH:Shane Herbert, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 11/25/2024 at 8:57 AM, Licensing Program Analyst (LPA) Zina Brown made an unannounced visit to the above facility. The purpose of today's visit was to conduct an annual inspection of the facility. On today's visit LPA met with facility Shane Herbert, Executive Director. The facility profile shows that the facility is licensed for a capacity of six (6) ambulatory adults ages 18-59. The executive director stated that the facility has four (4) clients currently enrolled in the program: (4) ambulatory and (0) non-ambulatory. The executive director stated none of the clients have restricted health care conditions or utilize any protective devices. The last medical emergency was conducted 09/30/2024. The last fire drill was conducted on 09/20/2024. The facility provides transportation. The liability insurance is current and expires 06/21/2024 The facility current has a annual licensing fee at a balance of $0.

The facility is a one (1) story home located in a residential neighborhood, the property consists of the following: 4 client bedrooms, 2 bathrooms, a staff restroom, nurses office, staff office, living room, kitchen, dining room, attached garage which houses the washer and dryer and an backyard with outdoor shaded area and a therapy room.

LPA conducted a records review of (4) client records, (4) staff records, were 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 Administrations 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: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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