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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601842
Report Date: 04/29/2024
Date Signed: 04/29/2024 03:20:55 PM

Document Has Been Signed on 04/29/2024 03:20 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SHERYL FACILITYFACILITY NUMBER:
198601842
ADMINISTRATOR/
DIRECTOR:		DAMIEKA LASLEYFACILITY TYPE:
735
ADDRESS:19514 SHERYL AVETELEPHONE:
(562) 964-4782
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 3CENSUS: 3DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Adminstrator Damieka Lasley TIME VISIT/
INSPECTION COMPLETED:
03:37 PM
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On 4/29/24 at 12:50 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Sheryl Facility. Upon arrival LPA was greeted by the Administrator, Damieka Lasley and LPA explained the reason for the visit. This home is licensed to serve (2) non-Ambulatory and (1) Ambulatory clients between the ages of 18-59. The level 4I home and the vendor is Harbor Regional Center. There were (0) clients in care during the time of this visit. Two (2) of the three (3) clients were at the day program and the last client was at a doctor’s visit. The last emergency disaster/fire drill was conducted on 4/8/2024. The Administrator Certificate expires on 02/23/2025 #6065800735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (3) client files, medications, medication administration records for (3) clients and P&I.

This home contains 3 bedrooms, 2 bathrooms, 1 living room/ office space, 1 living room with covered fireplace, laundry closet, kitchen, dining room and an attached garage. LPA toured the physical plant and observed all (3) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bars, and skid mat. The temperature measured at 109.9- 110.4*F. The smoke detectors and carbon dioxide were interconnected tested and observed to be working properly. There were (1) fire extinguisher located in kitchen and dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured over kitchen stove. The cleaning agents and toxins locked underneath kitchen sink. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. (Report continued 9099c)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SHERYL FACILITY
FACILITY NUMBER: 198601842
VISIT DATE: 04/29/2024
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained PPE supplies, storage, water, and toiletries.

Exit interview conducted with Damieka Lasley, Administrator, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC809 (FAS) - (06/04)
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