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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600768
Report Date: 12/22/2021
Date Signed: 12/22/2021 02:14:05 PM

Document Has Been Signed on 12/22/2021 02:14 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:MISS DAISY'S ADULT RESIDENTIALFACILITY NUMBER:
198600768
ADMINISTRATOR:BETTY BROWNFACILITY TYPE:
735
ADDRESS:1654 WEST 51ST PLACETELEPHONE:
(323) 296-7390
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY: 6CENSUS: 4DATE:
12/22/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Betty BrownTIME COMPLETED:
02:30 PM
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On 12/22/21, Licensing Program Analysts (LPAs) Gail Johnson and Ernand Dabuet conducted an unannounced Proof of Correction visit at the facility and met with licensee Betty Brown and explained the purpose of today’s visit is to conduct a plant inspection and health and safety check and provided consultation on CARE Inspection Advisories.

The facility was cited with a Type A Section 80087 (a) Personal Rights for failing to adhere to CCLD’s Mitigation Plan for not conducting COVID screening procedures with visitors, clients, and staff. In addition, citations were warranted with Type A 80087 for failing to keep sharp objects and toxic cleaning chemicals in secure locked compartments or drawers inaccessible to clients in care.

LPAs conducted a plant inspection by inspecting the interior and exterior of the facility. LPA observed that the Licensee corrected the violations. The facility is now in compliance with the California Code of Regulations Title 22 Division 6 Chapter 1.

An exit interview was conducted with Betty Brown and a copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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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