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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601458
Report Date: 12/09/2023
Date Signed: 12/09/2023 01:03:19 PM

Document Has Been Signed on 12/09/2023 01:03 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 HOME IIFACILITY NUMBER:
198601458
ADMINISTRATOR:ANDREW J. LEEFACILITY TYPE:
735
ADDRESS:21140 DENKERTELEPHONE:
(310) 877-9282
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 4DATE:
12/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:ISRAEL DIAZTIME COMPLETED:
01:30 PM
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On 12/09/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required inspection visit using the new CARE Inspection Tool.
Upon arriving at the facility, LPA met with Lee Thomas 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 four (4) ambulatory, clients ages 18-59.

The facility’s annual fees are current during today’s visit. Clients are referred by the Harbor Regional Center. Later, LPA was joined by the Manager Israel Diaz. LPA toured the single-story facility with staff Lee. The facility consists of four (4) client bedrooms, two (2) bathrooms, kitchen, dining area, living room, locked washer/dryer/storage room, garage, office and backyard patio.

The kitchen was inspected and there is at least a one week supply of nonperishable and two day supply of perishable foods. The facility is maintained at a comfortable temperature. The hot water temperature measures at 113.7 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.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2023
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LEE ADULT HOME II
FACILITY NUMBER: 198601458
VISIT DATE: 12/09/2023
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The facility has a written emergency disaster plan located in the office area. This facility has two operable carbon monoxide detectors located in the dining area and living room. 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 10/25/2023. Centrally stored medications are locked in a cabinet located in the kitchen.

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



There were no deficiencies cited. Technical Assistance was issued.

Exit interview conducted and a copy of this report was provided to Manager Israel Diaz.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023
LIC809 (FAS) - (06/04)
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