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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601618
Report Date: 03/17/2023
Date Signed: 10/12/2023 10:13:59 AM

Document Has Been Signed on 10/12/2023 10:13 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:YARBROUGH ADULT RESIDENTIAL FACILITY IIFACILITY NUMBER:
198601618
ADMINISTRATOR:DOLLIE YARBROUGHFACILITY TYPE:
735
ADDRESS:827 W 64TH STREETTELEPHONE:
(323) 750-1848
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 6CENSUS: 2DATE:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Troy BannerTIME COMPLETED:
12:00 PM
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On 03/17/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Facility manager Troy Banner and the purpose of today’s visit was explained. The facility is licensed to operate six (6) ambulatory adults only and the residents are South Central Regional Center residents.

The facility is a single-story home located in a residential neighborhood. The property consists of the following: 4 resident bedrooms, 2 common bathrooms, staff office, living room, kitchen, dining room, laundry room and an outdoor shaded area.

LPA conducted a records review of two (2) resident records, (5) staff records, and reviewed the facility disaster plan. All resident & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (2) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

LPA and Troy Banner toured the inside and outside of the facility. All resident rooms were checked, Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F (Bathroom #1 114. 2 F & Bathroom #2 116.3F).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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: YARBROUGH ADULT RESIDENTIAL FACILITY II
FACILITY NUMBER: 198601618
VISIT DATE: 03/17/2023
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to residents. Last fire drill conducted on 02/22/2023. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During today’s visit LPA did not observe any deficiencies.

Exit interview conducted with Troy Banner and a copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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