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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320423
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:13:34 PM

Document Has Been Signed on 08/21/2024 01:13 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:HAIGLER HOMEFACILITY NUMBER:
198320423
ADMINISTRATOR/
DIRECTOR:		DAVIS, RONALDFACILITY TYPE:
735
ADDRESS:19109 HAIGLER DRIVETELEPHONE:
(310) 817-4405
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: DATE:
08/21/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Ronald DavisTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 08/21/2024 at , 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 applicant Ronald Davis.

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 a TV, a kitchen, and a backyard accessible to residence. There is backyard, two (2) outside shaded patio areas outside on the premises. 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 (119.3 F) and bathroom #2 (112.1 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 garage, available for staff use but inaccessible to residence.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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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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: HAIGLER HOME
FACILITY NUMBER: 198320423
VISIT DATE: 08/21/2024
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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.

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. 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: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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