198320449-9-26-2024-11-AS-PBUR-D9GL7U-20240926083055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320449
Report Date: 09/25/2024
Date Signed: 09/26/2024 08:31:22 AM

Document Has Been Signed on 09/26/2024 08:31 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	LILLY'S SPECIALIZED FACILITY - W. 84TH PL		FACILITY NUMBER:	198320449
ADMINISTRATOR/ DIRECTOR:	DIRKS, LONDON		FACILITY TYPE:	735
ADDRESS:	2920 W. 84TH PL		TELEPHONE:	(323) 696-9323
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90305
CAPACITY: 4		CENSUS: 0	DATE:	09/25/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Lilly Jones		TIME VISIT/ INSPECTION COMPLETED:	02:45 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	Licensing Program Analyst (LPA) Pamela Bunker made an announced visit and met with Applicant Lilly Jones to conduct a Pre-Licensing evaluation. An application was submitted to the Department of Social Service; Community Care Licensing Division (CCLD) on 01/11/2024, for an initial application for Adult Residential for ages 18-59 years. The requested capacity is for four (4) ambulatory clients Structure: The facility is a two-story single-family home located in a residential neighborhood with four (4) bedrooms, three (3) full bathrooms, a living room, dining area, a den, kitchen, laundry room, office, and family room, The facility has a patio/shaded area and, an indoor/outdoor activity area located in the backyard. A two (2) car detached garage is located in the back left side of the property. Three (3) Exits are located in the living room, kitchen, and den. The front and backyard landscapes were in good condition at the time of the visit. Clients Bedrooms: There shall be no more than two clients per one bedroom. Bedrooms #1, #2, #3, and #4 are designated as the client's bedrooms and have one queen-size bed, chest of drawers, chair, nightstand, lamp, desk, television, closets, and drawer space. Staff Bedroom: There will be no living staff. Bathrooms: The bathrooms have a working toilet, wash basin, and bathtub/shower. Linens & Hygiene Supplies: The required linen/supplies include, a pillowcase, mattress padding, fitted sheet, blanket, and bedspreads. An adequate supply of linens is kept in the hallway linen closet. Hygiene supplies are stored in the kitchen cabinet. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in the front entranceway on the wall bulletin board. The facility has a landline telephone located in the kitchen and den. Three (3) fully charged fire extinguishers are located upstairs and downstairs in the kitchen, living room, and near the office area. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected, and in good repair, knives, cutlery, and other sharp kitchen utensils were locked in the kitchen cabinet drawer. See continued LIC809-C on page #2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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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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: LILLY'S SPECIALIZED FACILITY - W. 84TH PL	FACILITY NUMBER: 198320449
	VISIT DATE: 09/25/2024

NARRATIVE

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Continued LIC809-C page #2

Smoke/Carbon Monoxide Detectors: There are hardwire battery backup smoke alarms and carbon monoxide detectors located upstairs and downstairs in the living room, hallway, dining room near the kitchen, and bedrooms, which are operational. Appliances: Refrigerator, stove/oven, microwave, air fryer, blender, and washer/dryer are installed and all in working condition. There is central air and heat throughout the home. The hot water heater is outside located on the right side of the house. Toxins: Cleaning supplies and toxins will be stored locked in a separate cabinet located under the kitchen sink only accessible to clients. Water Temperature: The hot water tested in the kitchen and bathrooms temperature was tested at 115 degrees Fahrenheit within the normal limits (105-120F degrees). Medication, First-Aid Kit & Manual: Centrally stored medications will be locked in a cabinet in the kitchen. There are sufficient bandages, one (1) tweezer, a thermometer, scissors, and a first aid kit with manual. Staff & Clients Files: The staff and client's records will be kept confidential and stored in a locked file cabinet in the office. The applicant will manage clients' cash resources and ensure they are securely stored in a locked safe. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 05/24/2024. The facility yard is free of debris and hazards.

Component III Orientation:
Component III was completed with the Applicant Lilly Jones during the Pre-Licensing visit. Information was provided about how to operate the facility within substantial compliance. When the applicant was asked if she understood Title 22 Regulations she responded in the affirmative.

LPA Bunker will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, she has been instructed to communicate with the CAU Analyst assigned to their application.
An exit interview was conducted and a copy of this facility evaluation report (LIC809) has been furnished to the applicant.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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