198601364-9-30-2022-11-AS-PBUR-CJRPGC-20220930111806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601364
Report Date: 09/27/2022
Date Signed: 09/30/2022 11:18:09 AM

Document Has Been Signed on 09/30/2022 11:18 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:	HOME 2 U 3		FACILITY NUMBER:	198601364
ADMINISTRATOR:	GWENDOLYN COLE		FACILITY TYPE:	735
ADDRESS:	8940 S ST ANDREWS PL		TELEPHONE:	3107029572
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY: 4		CENSUS: 4	DATE:	09/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lydia Gamboa		TIME COMPLETED:	01:00 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 Pamela Bunker conducted an unannounced required annual visit. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Lydia Gamboa. LPA Bunker informed staff that the purpose of today's visit is to conduct an annual inspection of the facility, review the physical plant, medications, food service, staff, and client records, and verify that the administrator is present at the property 20+ hours per week. LPA Bunker verified all current staff fingerprints cleared/associated with the facility. The facility annual fees are current. There are currently four (4) South Central Los Angeles Regional Center (SCLARC) consumers in placement. LPA Bunker verified that the facility has an approved mitigation plan report. The facility staff and clients are COVID-19 vaccinated and boosted. The facility's annual fees are current. Staff Lydia Gamboa and LPA Bunker made a complete tour of the facility. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining room, kitchen, laundry room, 5 client bedrooms, 2 bathrooms, attached garage, shaded area, and indoor/outdoor activity areas. Bedrooms #1 thru #5 are designated as the client's bedrooms. See continued LIC 809-C on page #2

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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: HOME 2 U 3	FACILITY NUMBER: 198601364
	VISIT DATE: 09/27/2022

NARRATIVE

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Continued LIC 809-C page #2

Documents are posted as mandated on the wall in the facility living room on the bulletin boards. The following Title 22 regulated areas were audited and found to be in compliance: 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 with manual, hot water temperature 120 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, the fire extinguisher is fully charged, medications were centrally stored and properly locked in the dining area cabinet and records are current, ample supply of perishable and nonperishable food, adequate lights and linen supply, fire/emergency drill conducted on 01/20/2022. No firearms on the premises, the client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

The Administrator Certificate is current and expires on 03/01/2023. HIV/TB is also, current. Staff was given training on dependent adult and elder abuse reporting.

LPA Bunker provided staff Lydia Gamboa with a copy of the facility evaluation report.

There were no deficiencies cited.

Exit interview conducted

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC809 (FAS) - (06/04)

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