198601457-3-29-2023-11-AS-ARID-CQDVK4-20230329162944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601457
Report Date: 03/29/2023
Date Signed: 03/29/2023 04:29:51 PM

Document Has Been Signed on 03/29/2023 04:29 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:	LEE ADULT HOME		FACILITY NUMBER:	198601457
ADMINISTRATOR:	ANDREW J. LEE		FACILITY TYPE:	735
ADDRESS:	20121 GREVILLEA AVENUE		TELEPHONE:	(310) 877-9282
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 6		CENSUS: 4	DATE:	03/29/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	DWAIN GRIFFITH		TIME COMPLETED:	04:50 PM

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On 03/29/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the Care Inspection Tool.

LPA met with Administrator Dwain Griffith and explained the purpose of this visit. LPA was granted access and allowed to enter the facility to conduct an inspection. The facility is licensed to serve six (6) ambulatory clients, ages 18-59. Currently, there are four (4) clients and two (2) staff present during the visit. The facility’s annual fees are current during today’s visit. Clients are referred by the Harbor Regional Center.
LPA toured the single-story facility with Administrator Dwain Griffith. The facility consists of four (4) client bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining area, office area, living room, garage with a laundry room, and backyard patio.

The kitchen was inspected and there is at least a two weeks supply of nonperishable and seven days supply of perishable foods. The facility is maintained at a comfortable temperature. Hot water temperature measures at 118.3F degrees Fahrenheit. There are working lights in each room to ensure safety and comfort for all clients in the facility. All outdoor and indoor passageways were free of obstructions. The clients have clean linen which includes blankets/bedspreads, top and bottom sheets, pillow cases, and mattress pads. First aid kit had the required items. The facility has a written emergency disaster plan located in the office area. This facility has one operable carbon monoxide detectors located in the hallway. There are no pools or bodies of water on the premises. There are no firearms on the premises and other dangerous weapons. The last facility fire drill was on 03/21/2023. Centrally stored medications are locked in a cabinet located in the dining area.

The facility files were reviewed. Client files were randomly chosen for review. Clients medication assessments are complete and include TB information. Client have complete needs and service plans on file. Staff have criminal record clearances and that are associated to the program. Staff have proof of in service training. Staff files have complete health screenings and current first aid certificates.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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: LEE ADULT HOME	FACILITY NUMBER: 198601457
	VISIT DATE: 03/29/2023

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During the visit, LPA observed the following to be in compliance: 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 30-days supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

Exit interview held. A copy of the report and appeal rights were provided to Administrator Dwain Griffith.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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