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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601537
Report Date: 02/23/2022
Date Signed: 02/23/2022 11:43:07 AM

Document Has Been Signed on 02/23/2022 11:43 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:84TH STREET HOMEFACILITY NUMBER:
198601537
ADMINISTRATOR:LINDA HUDSONFACILITY TYPE:
735
ADDRESS:2111 WEST 84TH STREETTELEPHONE:
(323) 295-4555
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 6CENSUS: 6DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Alexander OfuonyeTIME COMPLETED:
11:50 AM
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02/23/22, Licensing Program Analysts (LPA) Gail Johnson conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Johnson met with the Director Alexander Ofuonye. LPA Johnson explained the purpose of today’s visit. The facility is licensed to operate six (6) ambulatory adults ages 18 through 59. Currently, six (6) clients reside at this facility.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms (three shared client bedrooms with two clients in each room), one (1) staff office area (located next the kitchen), two (2) bathrooms, living area, dining area, kitchen, outside table and covered area. LPA Johnson toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.6 degrees F.

Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Two fire extinguishers were fully charged, smoke detectors and carbon monoxide detectors
were operable.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: 84TH STREET HOME
FACILITY NUMBER: 198601537
VISIT DATE: 02/23/2022
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During the visit, LPA Johnson observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA Johnson observed staff was wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file.


An exit interview was conducted with Alexander Ofuonye . A copy of this report was printed and provided to Alexander Ofuonye.

End of report

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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