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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320475
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:32:27 PM

Document Has Been Signed on 04/25/2024 02:32 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:HEARTS UNITED, INC.FACILITY NUMBER:
198320475
ADMINISTRATOR/
DIRECTOR:		STEVENS, DONNAFACILITY TYPE:
735
ADDRESS:25032 ANDREO AVETELEPHONE:
(310) 961-8108
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 2CENSUS: 2DATE:
04/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:58 AM
MET WITH:ADMINISTRATOR DONNA STEVENSTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 04/25/2024 around 11AM Licensing Program Analysts (LPA) Jose Calderon conducted an announced visit to Hearts United Inc Facility located at 25032 Andreo Ave Lomita CA 90717 and met with Licensee/Administrator Donna Stevens for purpose of a pre-licensing evaluation. The requested capacity is for 2 ambulatory Adult Resident Facility.

Facility is a 3 bedroom, 2 bathrooms, two-story house. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a backyard with a covered patio for shade. The patio contained 1 small table and 3 chairs. Outdoor passageways, walkways, driveways, steps, and patios are free from obstructions. LPA Calderon did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Residents Bedrooms: All 3 Bedrooms are for ambulatory clients. Bedroom’s #1 and #2 will have one bed each, one chair, one-night stand, one lamp when facility move is finished on 04/26/2024. Prior facility address located at 2427 W 239th Street Torrance CA 90501 was inspected by LPA Calderon on 04/25/2024 and has the required physical plant items to move to the new location. Bedroom #3 is for the Licensee/Administrator Donna Stevens use only. Bedrooms #1, #2 and #3 all comply with the requirement of 8 cubic feet of space. Bathroom: Have a working toilet, wash basins, and walk-in shower. Bathroom #1 shower is missing grab bars, but licensee states bathroom #1 is for ambulatory only residents. LPA Calderon observed adequate lighting in hallway leading to bathrooms. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet was noted.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 3
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: HEARTS UNITED, INC.
FACILITY NUMBER: 198320475
VISIT DATE: 04/25/2024
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Emergency Phone Numbers, Exit Plan & Menu: The telephone system is a land line and operable. Emergency Disaster Plan and "See something, say something Let Us Know" were missing but signage will be displayed no later than 04/26/2024. Fire Extinguisher 1 mounted on the wall next to the kitchen.
Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a lock box located in the kitchen area. Food supply is adequate; stored in kitchen refrigerator and cabinets and consists of the following: A variety of Fresh and Canned fruit, vegetable, and meat food items. Smoke Detectors/carbon monoxide: 8 hard wired smoke detectors are operated & working. Appliances: Gas Stove, oven, microwave, washer, and dryer working. Refrigerator in the kitchen has a measured temperature of at least 37 degrees Fahrenheit for appropriate food storage. Freezer is at zero degrees Fahrenheit. The 2 refrigerators located in the garage has a measured temperature of at least 37 degrees Fahrenheit for appropriate food storage. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: Locked/stored in a cabinet located in the kitchen. Water Temperature: Bathrooms water temperature tested in #1 at 117 F. and #2 at 116 F. degrees. Kitchen water temperature tested at 118 degrees. Medications, First-Aid Kit & Book: Medication administration records storage area, and first aid kit has been inspected, which are stored in lock box located in a cabinet adjacent the refrigerator, available for staff use but inaccessible to clients.

Clients & Staff Files: Applicant will be handling cash resources of clients and has a surety bond with Western Surety Company #66993979 for $2000.00. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked in staff office and the section has been inspected.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HEARTS UNITED, INC.
FACILITY NUMBER: 198320475
VISIT DATE: 04/25/2024
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Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. LPA Calderon did not observe any pet or bodies of water at the facility. LPA Calderon did not observe delayed egress, chain locks or dead bolts on exits. LPA Calderon did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Pool/Jacuzzi & Pets: LPA Calderon did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 04/17/2024 for 2 ambulatory clients with no special instructions.

Component III: (04/25/2024) about how to operate the facility within substantial compliance was reviewed with licensee Donna Stevens.

An exit interview was conducted, and a copy of this report has been furnished to the applicant Donna Stevens by hand. Accordingly, LPA Jose Calderon 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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