<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320422
Report Date: 09/05/2024
Date Signed: 09/05/2024 11:13:04 AM

Document Has Been Signed on 09/05/2024 11:13 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:SHERMAN HOUSEFACILITY NUMBER:
198320422
ADMINISTRATOR/
DIRECTOR:		BARBER, CANDACEFACILITY TYPE:
735
ADDRESS:318 E. SHERMAN DRIVETELEPHONE:
(310) 817-4383
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: DATE:
09/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:43 AM
MET WITH:Candace BarberTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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 09/05/2024 at 08:40am, Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager Janae Hammond conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA Zina Brown met with aplicant Candace Barber.
p
An application was submitted to CCLD on 09/11/2023, for an Adult Residential Facility (ARF) to serve adults for ages 18 through 59. The requested capacity is for four (4) residents.

Structure:
The facility is a (4) bedroom, (2) bathroom, single story house with a attached garage. The facility is a structure with bedrooms, bathrooms, living room with TV, a kitchen (with the water temperature at 106.5F) , and a backyard accessible to residence. There is backyard, one outside shaded area with a shed for office use. The resident has (4) four bedrooms that are spacious and are easily accommodate the residence furnishings.

Bedroom Structure
All (4) four bedrooms have the following one (1) bed, one (1) lamp, one (1) night stand, one (1) television, one(1) dresser, one (1) closet, and one (1) chair .

Bathroom Structure
All bathrooms have a working toilet, wash basin, and shower . All bathrooms can accommodate ambulatory clients. Water temperature for each bathroom are as followed bathroom #1 (113.5 F) and bathroom #2 (117.9 F).

Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following tweezers, scissors, antiseptic, bandages, , thermometer and current first aid manual, which are stored in kitchen, available for staff use but inaccessible to residence.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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 2
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: SHERMAN HOUSE
FACILITY NUMBER: 198320422
VISIT DATE: 09/05/2024
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
26
27
28
29
30
31
32
Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following tweezers, scissors, antiseptic, and bandages, which are stored in kitchen, available for staff use but inaccessible to residence.

Clients & Staff Files:


At the time of pre-licensing, no client and staff files were reviewed as the facility is awaiting approval for licensing.

Fire clearance:
Fire clearance for four (4) ambulatory at the Adult Residential Facility for the adults was approved on 03/26/2024.

Pre-licensing Checklist: Completed by licensee and reviewed by LPA.

Component III:
During the conducted pre-licensing visit, an orientation of the component III information was provided to the licensee and employees about how to operate the facility within substantial compliance.

The following items need to be corrected prior to licensor by Friday, September 13, 2024
  • Thermostats

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA Zina Brown will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review once the corrections are made by the facility. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2