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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601508
Report Date: 06/16/2023
Date Signed: 09/30/2023 08:18:08 AM

Document Has Been Signed on 09/30/2023 08:18 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:HOLMAN'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601508
ADMINISTRATOR:KASHSAI GOODWINFACILITY TYPE:
735
ADDRESS:1552 EAST 118TH PLACETELEPHONE:
(323) 567-0745
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY: 4CENSUS: DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:RachelTIME COMPLETED:
11:16 AM
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Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Rachel, Staff, and the purpose of today’s visit was explained. The facility is licensed to serve (4) Developmentally- Disabled adults which may include (2) ambulatory and (2) non-ambulatory ages 18 years - 59 years.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms and one is used as a file/storage room, 2 bathrooms, living room, dining room, kitchen with eating area, and laundry room/ office.

LPA and Staff Shenesia Gladney, DSP toured the physical plant. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms was found to be within Title 22 regulations and were clean and operational. The water temperature measured 102.5. A comfortable temperature is maintained in the facility.

LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable

During today’s visit there were no deficiencies observed.

An exit interview held. A copy of the report was provided to Shenesia Gladney.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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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