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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601844
Report Date: 03/07/2022
Date Signed: 03/07/2022 03:31:21 PM

Document Has Been Signed on 03/07/2022 03:31 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PEPPERWOOD AVENUE FACILITYFACILITY NUMBER:
198601844
ADMINISTRATOR:HAMPTON, SHELEANIA "CHINA"FACILITY TYPE:
735
ADDRESS:4735 PEPPERWOOD AVETELEPHONE:
(562) 982-4237
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 3CENSUS: 3DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Renee DavenportTIME COMPLETED:
03:45 PM
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On 03/07/22 Licensing Program Analyst (LPA) Jade Jordan Conducted an unannounced annual inspection with an emphasis on infection control. LPA was met by facility administrator Renee, and the purpose of the visit was explained.

Upon Entry, LPA observed Covid-19 postings, and LPA was screened for Covid-19 symptoms, including temperature check.

The facility is a 3 bed room house located in a residential neighborhood. The interior consists of the following: Living room , dining area, kitchen, (3) client bedrooms ( all rooms are single occupancy), and (3) bathrooms. The exterior consisted of outdoor patio activity area, with a detached locked garage, used for storage. All Bedrooms have required furnishings including Bedspreads, comforters, dressers, chair, adequate lighting, closet space. Each bedroom has an exit door. All bathrooms were clean and sanitary, free of mold and mildew. Bathrooms had paper towels, and soap for good hand hygiene. Sufficient toiletries, linens towels and bedding for clients were available. Hot water was tested and noted at 112.1 degrees.
There was plenty of non perishable, and perishable foods. There are working lights throughout the facility. Carbon monoxide and smoke detectors are dual devices and were tested and are operational. The Administrator's certificate expires 08/09/2023
The home is vendorized through the Harbor Regional Center. During this visit LPA reviewed client records, staff records, PNI and medications. Fire drills are conducted and documented every month. Last drill was performed on 02/01/22..
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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: PEPPERWOOD AVENUE FACILITY
FACILITY NUMBER: 198601844
VISIT DATE: 03/07/2022
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A minimum of 30 day supply of PPE were observed. ( N95, Surgical masks, gloves, face shield, gowns, sanitizer, soap, paper towels.) LPA observed Client daily temperature log, visitor log, and freestanding thermometer. N95 fit testing was conducted for staff on 01/31/22.

No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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