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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601844
Report Date: 05/05/2024
Date Signed: 05/05/2024 02:20:44 PM

Document Has Been Signed on 05/05/2024 02:20 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PEPPERWOOD AVENUE FACILITYFACILITY NUMBER:
198601844
ADMINISTRATOR/
DIRECTOR:		DAVENPORT, RENEEFACILITY TYPE:
735
ADDRESS:4735 PEPPERWOOD AVETELEPHONE:
(562) 982-4237
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 3CENSUS: 3DATE:
05/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:02 AM
MET WITH:RENEE DAVENPORT TIME VISIT/
INSPECTION COMPLETED:
02:38 PM
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On 05/05/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Program Manager Renee Davenport. LPA explained the purpose of the visit. The facility is licensed for (3) non-ambulatory adults ages 18-59 years of age. Currently, the home has (3) clients. They are consumers of Harbor Regional Center clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) clients' rooms, two (2) common bathrooms and one (1) private bathroom, a laundry room, a living area, a dining area, a kitchen, a den, and an outside patio area.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational. The water temperature measured 105.0 - 120.0 F. A comfortable temperature of 69 degrees F was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. A working landline telephone was available and operable.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PEPPERWOOD AVENUE FACILITY
FACILITY NUMBER: 198601844
VISIT DATE: 05/05/2024
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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. Disaster and fire drills with all shifts are conducted quarterly, the last being completed on 01/05/24.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

LPA conducted an audit of client #1-#3 (C1-C3) service files, and staff #1-#4 (S1-S4) personnel files were in order and complete. Interviews conducted with (2) facility staff and attempted interviews with (3) clients.

The facility is current in CCLD annual fees. The facility has a current administrator certificate for Sheleania Hampton #6001450735 valid through 6/7/2025. The facility has in an effect a Surety Bond established 01/15/14. The facility has a current liability insurance effective 01/02/24 thru 01/01/25.

No deficiencies during this visit.

An exit interview conducted with Renee Davenport and a copy of the report is provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2024
LIC809 (FAS) - (06/04)
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