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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600426
Report Date: 06/14/2022
Date Signed: 06/14/2022 12:41:20 PM

Document Has Been Signed on 06/14/2022 12:41 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:C-H #5 RESIDENTIAL FACILITYFACILITY NUMBER:
198600426
ADMINISTRATOR:JEFFERSON, REBEKAHFACILITY TYPE:
735
ADDRESS:14750 WIEMER AVETELEPHONE:
(562) 634-4151
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 3CENSUS: 2DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rebekah Jefferson - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Administrator Rebekah Jefferson and explained the reason for the visit. The facility is licensed to serve 3 developmentally disabled adults ages 18 thru 59 years old, ambulatory only. There are currently 2 ambulatory clients serviced by South Central Los Angeles Regional Center.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the living room, kitchen, dining area, 3 client bedrooms, 2 bathrooms, laundry area, recreational room, front yard, backyard, and attached garage.

LPA Mora conducted the tour with Rebekah Jefferson and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen and garage refrigerators. Sharps, chemical and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept in a living room cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in a hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a laundry room cabinet. Staff files are kept in the medication cabinet. Client files are kept in a cabinet near the living room. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 106.1 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. There is a carbon monoxide in the kitchen and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: C-H #5 RESIDENTIAL FACILITY
FACILITY NUMBER: 198600426
VISIT DATE: 06/14/2022
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LPA reviewed medication for 2 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for 2 clients and 2 staff. LPA observed administrator certificate for Rebekah Jefferson - 6014869735 with an expiration date of 03/31/2022. Administrator provided LPA with renewal documentation dated 03/28/2022. LPA reviewed the pending application list and observed the administrators name on the list.

Facility has 30 days supplies of Personal Protective Equipment in the recreational room. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report were provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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