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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600661
Report Date: 02/25/2022
Date Signed: 02/25/2022 11:47:45 PM

Document Has Been Signed on 02/25/2022 11:47 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:OUR HOUSE THEATRICAL LIVING & LEARNING CENTERFACILITY NUMBER:
198600661
ADMINISTRATOR:SHAHWAN, BARBARAFACILITY TYPE:
775
ADDRESS:1123 E DOMINGUEZ ST. SUITE CTELEPHONE:
(310) 763-4998
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 80CENSUS: 30DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Gisela Acosta-Program DirectorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Gisela Acosta, Program Director and the purpose of today’s visit was explained. The facility is licensed to serve (80) adults, which of (78) may be non-ambulatory

Inspection consisted of the following: LPA toured the facility with Program Director and there were currently 30 clients and the facility. LPA observed all clients appeared to be fine. The facility is a single-story structure located in a commercial building. LPA reviewed 3 clients records that consisted of their emergency and physicians report. The program is located one large building consisting of the following: Parking lot (drop off/pick up area), Kitchen, 1 large activity room, 1 changing/isolation room. 1 nurse room, 3 client restrooms, 2 staff restroom, conference room and offices. Facility walls and floors were in good condition, adequate lighting, fire extinguishers were properly charged. Plenty of storage space and chemicals were properly locked. The restrooms were clean and within Title 22 regulations. The water temperature measured at 120F . The kitchen was clean and a refrigerators are available for client use. The day program does not provide lunch however, snacks are available to clients. Carbon Monoxide detector was observed. The first aid kit was available; medications were locked and inaccessible to clients. Walkways throughout the day program were clear of hazards and all exits were clear of debris.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LIC 809-C is on the next page.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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 2
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: OUR HOUSE THEATRICAL LIVING & LEARNING CENTER
FACILITY NUMBER: 198600661
VISIT DATE: 02/25/2022
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview conducted and a copy of this report was provided to the Program Director.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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