198600426-5-23-2023-28-AS-LMOA-CS4R92-20230523124850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600426
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:49:16 PM

Document Has Been Signed on 05/23/2023 12:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	C-H #5 RESIDENTIAL FACILITY		FACILITY NUMBER:	198600426
ADMINISTRATOR:	JEFFERSON, REBEKAH		FACILITY TYPE:	735
ADDRESS:	14750 WIEMER AVE		TELEPHONE:	(562) 634-4151
CITY:	PARAMOUNT	STATE: CA	ZIP CODE:	90723
CAPACITY: 3		CENSUS: 2	DATE:	05/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Rebekah Jefferson - Administrator		TIME COMPLETED:	01:03 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) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Rebekah Jefferson (Administrator) 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. The facility is operating within the scope of its license and currently have 2 clients. 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 the 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 109.2 degrees F and 110.1 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 809-C)

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C-H #5 RESIDENTIAL FACILITY	FACILITY NUMBER: 198600426
	VISIT DATE: 05/23/2023

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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 5 staff. LPA observed administrator certificate for Rebekah Jefferson - 6014869735 with an expiration date of 03/31/2024. LPA interviewed 2 staff and was unable to interview the clients due to the clients being at the Adult Day Program (ADP) at the time of this visit.

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: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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