198600862-9-9-2022-11-AS-PSCT-CJ4QPT-20220909122115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600862
Report Date: 09/09/2022
Date Signed: 09/09/2022 12:21:30 PM

Document Has Been Signed on 09/09/2022 12:21 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:	CHALLENGE FOUR		FACILITY NUMBER:	198600862
ADMINISTRATOR:	LAWRENCE PHILLIPS		FACILITY TYPE:	735
ADDRESS:	11700 LEMOLI AVE		TELEPHONE:	(323) 815-9881
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90303
CAPACITY: 4		CENSUS: 4	DATE:	09/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Randolph Dillon		TIME COMPLETED:	12:45 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 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 administrator, Randolph Dillon, and the purpose of the visit was explained. Upon entry, my temperature was taken, and I was presented with a visitor’s log to sign in. Mr. Dillon was wearing a mask. The facility has a capacity for four (4) residents, all ambulatories. The facility is a single-story family home located in a residential neighborhood. Mr. Dillon and LPA Scott made a complete tour of the adult residential home inside and out. It consisted of the following: Living room, dining room, kitchen, office, 3 bedrooms, 2 bathrooms, laundry area, detached garage, shaded area, and indoor/outdoor activity areas. 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. The facility has the mandated COVID infection control posters as well as facility license, floor plan, administrators’ certificate, and emergency evacuation plan etc. Continued LIC 809-C page #2

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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: CHALLENGE FOUR	FACILITY NUMBER: 198600862
	VISIT DATE: 09/09/2022

NARRATIVE

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Documents are posted as mandated in the facility dining room bulletin board. 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 and operational. First aid kit is fully stocked, hot water temperature registered 116.1 degrees Fahrenheit. There is a working telephone, smoke and carbon monoxide detectors were complying, fire extinguisher is charged, medications were centrally stored and properly locked in the kitchen cabinet and records are current.

There is an ample supply of perishable and nonperishable food, all lights were operable, and the linen supply was abundant. Fire/emergency drill conducted on July 27, 2022. No firearms on the premises, and no bodies of water were present. Hazardous items are inaccessible to clients, yard was free of debris and hazards. Knives and toxins were locked as well.

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; 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.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1), there were no deficiencies cited at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the administrator Randolph Dillon.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC809 (FAS) - (06/04)

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