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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320442
Report Date: 07/18/2024
Date Signed: 07/18/2024 12:34:30 PM

Document Has Been Signed on 07/18/2024 12:34 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:HUGS HOME ADULT RESIDENTIAL CAREFACILITY NUMBER:
198320442
ADMINISTRATOR/
DIRECTOR:		THOMAS, RICKAFACILITY TYPE:
735
ADDRESS:5520 EILEEN AVENUETELEPHONE:
(562) 489-4279
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 4CENSUS: 0DATE:
07/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Ricka ThomasTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On July 18, 2024 at 9:00am, Licensing Program Analyst (LPA), Deborah Lee and Licensing Program Analyst (LPA) Wendy Gibbs, conducted an announced visit to the facility for the purpose of conducting a pre-licensing evaluation. An application was submitted to CCLD on12/28/23 for opening a new facility for an Adult Residential Facility (ARF) to serve Developmentally Disabled Adults for ages 18 to 59 years for 4 ambulatory clients. LPAs met with Ricka Thomas, Applicant, and Kimberly McCarter, DSP and explained that the purpose of today’s visit together toured the physical plant (inside and outside).

Overview of Facility:

Facility is a single-story home located in a residential neighborhood. There are 2 resident bedrooms, 1 bathroom, dining room, living room, laundry closet attached to kitchen, and 2-car detached garage. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a back yard with patio furniture with umbrella. Outdoor passageways, walkways, driveways, steps, and patios are free from obstructions. LPAs did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms clients: observed all required postings:
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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HUGS HOME ADULT RESIDENTIAL CARE
FACILITY NUMBER: 198320442
VISIT DATE: 07/18/2024
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Smoke Detectors: Facility has 5 smoke detectors and 3 carbon monoxide detectors. All were tested and are operable. Appliances: LPA observed all kitchen appliances and washer and dryer in working order. LPAs observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. The residence is equipped with heat and air conditioning. Toxins: Applicant showed LPAs, where toxins to be locked/stored. Water Temperature: Tested at 117-degrees (kitchen) and 112-degrees (bathroom). Files: Applicant will be handling cash resources of clients as needed, and will be secured in a locked box, secured in a locked closest in the entrance of the facility.

Bedrooms 1 and 2 have the required furniture including bed, dresser, night stand with lamp, chair, and storage space for personal belongings. All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. All bedrooms had working lights, new blinds and working windows with no bars, and will be occupied by 2 clients Bathrooms: There is one Bathroom located in the hallway and has a working toilet, wash basins and shower, LPAs observed it to be clean, safe, and sanitary. LPAs observed non-skid material in the shower. LPAs observed adequate lighting in hallway leading to bathroom. Linens & Hygiene Supplies: Extra linens are in hallway closet. LPAs observed an ample supply of hygiene products available for residents in the hall closet.


Living room is fully furnished with sofa, 2 chairs coffee table and 2 lamps, small desk working station with computer for staff along a desk for client use. LPAs also observed games and activities available for client use. There is a small sanitation at front entry of facility.Page 2 of 3
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
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: HUGS HOME ADULT RESIDENTIAL CARE
FACILITY NUMBER: 198320442
VISIT DATE: 07/18/2024
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Facility has a working landline phone for emergencies. Fire Extinguishers (2) are fully functioning/charged. LPAs observed sample activities schedule and menu.

Client files will be secured in a locked closet in the entrance of the facility. Staff files will be stored in locked drawer located in small office space off of living room area. Medications LPAs observed boxes secured in a locked closet, in the entrance of the facility, where medications are to be stored. LPAs observed two First Aid Kits, fully stocked with the required items, and a current manual.



LPAs did not observe any pets or bodies of water at the facility.

Component III: LPAs and Administrator reviewed and discussed Component III.

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

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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