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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600989
Report Date: 12/09/2022
Date Signed: 12/09/2022 11:52:35 AM

Document Has Been Signed on 12/09/2022 11:52 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:D.A.D. 365 ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198600989
ADMINISTRATOR:SANDRA SMITHFACILITY TYPE:
735
ADDRESS:2682 SOUTH HARCOURT AVENUETELEPHONE:
(323) 632-6557
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY: 3CENSUS: 2DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Sandra Smith - AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Sandra Smith, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve 3 developmentally disabled clients (age 18-59) and is approved for 3 ambulatory clients. Currently, there are 2 clients in placement through South Central Los Angeles Regional Center. As a part of the inspection, LPA reviewed the infection control policy and inspected the entire facility. Fire drills are conducted monthly and the last fire drill was conducted 12/08/22.

The facility is a single-story structure located in a residential neighborhood. LPA Leon and Administrator toured the entire facility inside and out. The home consists of 3 client bedrooms, 2 bathrooms, living room, dining room and kitchen. All clients bedrooms were checked. Mattresses were in good condition, adequate lighting in rooms, plenty of dresser and closet space observed. Walls and floors were clean and in good repair. Comforters, bed linens, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and sufficient toiletries accessible to clients. Water temperature was measured at 110.6 F in bathroom one (1), 109.7 F in bathroom two (2) and 109 F in kitchen.

Perishable and non-perishable food supply was checked and appeared to be adequately stocked at time of visit. Carbon Monoxide detector was operational. Smoke detectors were working properly, in unison with ADT security. All three (3) fire extinguishers were fully charged. The facility stores toxins and knives in a secured inaccessible area, in hallway outside of bathroom two (2). Medications are properly locked and in a centrally stored area. Outside grounds were toured and no bodies of water were observed. Covered patio with furniture was accessible. Exits/ Walkways around the home were free of debris and hazards. First Aid Kit was fully stocked with scissors and tweezers. No weapons or firearms were locate on property.
See LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: D.A.D. 365 ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198600989
VISIT DATE: 12/09/2022
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located throughout all common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and required postings were present throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE), stored in the detached garage.

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

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Sandra Smith

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
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