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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601457
Report Date: 03/13/2024
Date Signed: 03/13/2024 01:25:31 PM

Document Has Been Signed on 03/13/2024 01:25 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:LEE ADULT HOMEFACILITY NUMBER:
198601457
ADMINISTRATOR:ANDREW J. LEEFACILITY TYPE:
735
ADDRESS:20121 GREVILLEA AVENUETELEPHONE:
(310) 877-9282
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 4DATE:
03/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Administrator Dwain GriffithTIME COMPLETED:
01:40 PM
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On 03/13/24 at 11:04 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator Dwain Griffith. LPA explained the purpose of the visit and was accompanied by Administrator inside and outside the facility during this inspection. Annual Fees are current.

The home 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 Facility is licensed to serve up to 6 ambulatory clients ages 18-59.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

4 out of 4 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Cloyd tested hot water temperature and it measured between 119.6 degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.



LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 02/14/24. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LEE ADULT HOME
FACILITY NUMBER: 198601457
VISIT DATE: 03/13/2024
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Five (5) staff records were reviewed, 5 out of 5 staff records had current first aid certificates. One staff member was interviewed.

Four (4) client records were reviewed and, 4 out of 4 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. Two client medications were reviewed. LPA Cloyd reviewed P&I money, 3 out of 3 clients' P&I were intact and were not commingled with facility funds or petty cash.

No deficiencies cited.

An exit interview was conducted and technical assistance provided. A copy of this report was discussed and left with the Administrator Dwain Griffith.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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