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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320468
Report Date: 01/17/2025
Date Signed: 01/17/2025 11:10:03 AM

Document Has Been Signed on 01/17/2025 11:10 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:QUINCY MANORFACILITY NUMBER:
198320468
ADMINISTRATOR/
DIRECTOR:		CHAVEZ, JOSIEFACILITY TYPE:
735
ADDRESS:113-115 N. CHESTER AVE.TELEPHONE:
(310) 635-9959
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY: 12CENSUS: 12DATE:
01/17/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Administrator Josie ChavezTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 01/17/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted an announced pre-licensing evaluation for change of Ownership (CHOW). The facility type is an ARF (Adult residential facility). LPA met with Administrator Josie Chavez.

An application was submitted to CCLD on March 11th, 2024, for Initial license for an Adult Residential Facility for (12) developmentally disabled adults ages 18 to 59. There is a fire clearance for (12) non-ambulatory clients. Fire clearance approved on October 21st, 2024, by the City of Compton fire department, surety bond obtained on 02/19/2024 and remains effective as long as the license is valid (Bond # 394081G, Brooklyn Ventures LLC dba suretybonds.com), and infection control plan has been submitted.

Facility consists of (2) single-story homes (113 and 115) located in a residential neighborhood and consist of the following: Front house 113 consist of (4) bedrooms, (1) shared bathroom, and (1) staff bathroom, (1)staff office located next to the entry way, a day room, lobby, a kitchen, a staff office where the medications are stored under lock, and (3) exit doors. The back house 115 consist of (5) bedrooms of which bedroom #5 has a private bathroom, a living room, a Jack and Jill bathroom between bedrooms #6 and #7, which also has a door in the living room for access. There is a detached garage used as storage, the garage has an attached room that house a washer and dryer. Passageways, walkways, driveways, steps, and patios are free from obstructions. No bodies of water nor firearms are on the property.

The client bedrooms are spacious and will easily accommodate the client's furnishings. Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen and hygiene products stored in a cabinet in the hallway.

Posted & readily available for review in den area is the emergency disaster plan, emergency phone numbers, menu, clients rights, administrator certificate and visitors policy. The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. A total of (4) fire
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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: QUINCY MANOR
FACILITY NUMBER: 198320468
VISIT DATE: 01/17/2025
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extinguisher observed, (1) is mounted in kitchen, (1) underneath kitchen sink, (1) mounted in the front house lobby, and (1) mounted in the back house living room. Smoke and carbon monoxide detectors are interconnected and are operational. A landline and internet service were observed. Dishes, cups, and flat ware are stored in the kitchen cupboards, and are in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer in the kitchen area. Stove burners, microwave, refrigerator, and freezer are all operational. Refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezers are at (0) zero degrees F. and water temperatures measured between 105-120 degrees F. A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the front house office, available for staff use but inaccessible to clients. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff, along with staff and client records which shall be stored in a locked cabinet in the dining area and the section has been inspected. LPA reviewed (4) client records, (4) P&I ledgers and (4) medication records, (2) staff records, no discrepancies. Last fire drill was conducted on 09/6/2024.

The following items need to be correct by Friday 01/31/25;
-required furniture in client bedrooms (1) chair per client.
-obtain and place living room furniture in back house
-Ensure bedroom windows and window screens are clean and it good repair
-Personnel files- Each staff should have completed and documented the required training's for title 22 regulations as well as all training's listed on the plan of operations.
-update facility sketch to show Jack and Jill bathroom between bedrooms #6 and #7.
As of 01/17/25 Quincy Manor is not ready to be licensed until all the items listed above are corrected.

Exit interview conducted with Administrator Josie Chavez and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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