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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600778
Report Date: 09/22/2022
Date Signed: 09/22/2022 02:11:03 PM

Document Has Been Signed on 09/22/2022 02:11 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:AHMEN RESIDENTIAL FACILITYFACILITY NUMBER:
198600778
ADMINISTRATOR:DEBRA ADEWALEFACILITY TYPE:
735
ADDRESS:9618 SOUTH 8TH AVENUETELEPHONE:
(323) 779-5324
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY: 3CENSUS: 3DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Debra AdewaleTIME COMPLETED:
02:15 PM
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On 09/22/22, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA Scott met with Debra Adewale. LPA was properly screened for Covid-19 symptoms and temperature was checked and logged. The facilities annual fees are current.


The facility is a single-story family home located in a residential neighborhood. LPA and Stephanie Staine (staff) made a complete tour of the facility which consisted of: Living room, three (3) bedrooms, two (2) bathrooms, dining area, kitchen, den, laundry room, detached garage, shaded area, indoor/outdoor activity areas. Each bedroom has one client to a room. Currently, there are three clients (3) two (2) ambulatory and one (1) nonambulatory.

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 additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. And the facility has the mandated COVID infection control posters.

Documents are posted as mandated on the living room wall. The following Title 22 Regulated areas were audited and found to be complying: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean. First aid kit is fully stocked with manual, hot water temperature 116.5 degrees Fahrenheit, there is a working telephone, smoke and carbon monoxide detectors were complying, fire extinguisher is fully charged, and medications were centrally stored and properly locked in toolboxes in the kitchen. Fire inspection/drill was conducted on 06/15/22.
Continued LIC809-C page #2
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AHMEN RESIDENTIAL FACILITY
FACILITY NUMBER: 198600778
VISIT DATE: 09/22/2022
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Documents are posted as mandated on the living room wall. The following Title 22 Regulated areas were audited and found to be complying: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean. First aid kit is fully stocked with manual, hot water temperature 116.5 degrees Fahrenheit, there is a working telephone, smoke and carbon monoxide detectors were complying, fire extinguisher is fully charged, and medications were centrally stored and properly locked in toolboxes in the kitchen. Fire inspection/drill was conducted on 06/15/22.

There is an ample supply of perishable and nonperishable food and an adequate supply of linens. There are no firearms are on the premises. All exit doors were complying, covered trash cans were observable, and no bodies of water present. Hazardous items are inaccessible to clients, and the yard is free of debris and hazards.

During the visit, LPA observed the following to be complying: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 90-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

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

No deficiencies cited and a copy of the Facility Evaluation Report was furnished to Debra Adewale.

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

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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