<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600661
Report Date: 01/26/2023
Date Signed: 01/26/2023 10:12:22 AM

Document Has Been Signed on 01/26/2023 10:12 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, 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: 52DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gisela Carter AcostaTIME COMPLETED:
11:00 AM
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
On 1/26/2023 at 9:00am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit with a primary focus on infection control measures. LPA was met by Gisela Carter Acosta, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve (80) adults, of which (78) may be non-ambulatory. As of today, the facilities annual fees are due.

As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has the mandated COVID infection control posters.

LPA Scott toured the facility with Ms. Carter Acosta. The facility is a single-story structure located in a commercial building. The facility is 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.

Continued on LIC809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: OUR HOUSE THEATRICAL LIVING & LEARNING CENTER
FACILITY NUMBER: 198600661
VISIT DATE: 01/26/2023
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
26
27
28
29
30
31
32
The restrooms were clean and within Title 22 regulations. The water temperature measured at 106.6 F. The kitchen was clean, and there were two refrigerators designated for client/staff use. The day program does not provide lunch; however, snacks are available to clients. Smog/Carbon Monoxide detectors were operable. The first aid kit was available with manual. Walkways throughout the day program were clear of hazards and all exits were clear of debris. The last emergency/fire drill was completed on 12/27/22.

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 was wearing face coverings, and the required postings were posted throughout the facility. LPA observed the facility has a 90-day supply of Personal Protective Equipment (PPE). LPA’s temperature was taken as well as instructions on where to sign in for the visitor’s logbook.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance.

No deficiencies were cited during this inspection visit.

Exit interview conducted and a copy of the facility evaluation report was provided to the Gisela Carter Acosta, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2