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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601844
Report Date: 03/17/2025
Date Signed: 03/18/2025 12:22:00 PM

Document Has Been Signed on 03/18/2025 12:22 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:
03/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:09 AM
MET WITH:Jolanda Cartridge, Client Care CoordinatorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 03/16/2025 at 8:03 am Licensing Program Analyst (LPA) Zina Brown arrived at the facility. At 8:15 am LPA entered the facility to conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. At 10:17 am, the Client Care Coordinator Jolanda Cartridge arrived to the facility and met with LPA who discussed the purpose of the visit. The facility is licensed to operate for three (3) non-ambulatory, developmentally disabled adults ages 18 through 59. Currently, the home has (3) clients. The clients are Harbor Regional Center clients. None the clients have Restricted Health Care. Conditions and none are utilizing postural supports or protective devices. The facility fees are current. The facility has liability insurance Nationwide Mutual Insurance Company (NAIC #25443) effective 1/1/2025 - 1/05/2026 policy number # ACPCG0230595558980 with each occurrence at $1,000,00 and general aggregate at $3,000,000.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) clients' bedrooms, two (2) common bathrooms and one (1) private bathroom (water tested at 110.3F), a laundry room, a living area, a dining area, a kitchen, a den,a garage and an outside patio area.



Between the hours of 8:35 am - 9:20 am, LPA conducted a records review of the Medication Administrator Records for (3) residents. Between hours of 10:25am - 11:05 am, LPA conducted a records review for (4) resident records, (5) staff records, (2) Personal & Incidental records and and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan (last conducted on 02.22.2025) was current and in compliance with Title 22 at the time of visit.

At 11:40am - 11:57am LPA and Jolanda Cartridge toured the inside and outside of the facility. All client 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: 119.0 F & Bathroom #2: 114.8F and 113.8F).

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 03/17/2025
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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 clients. 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 todays visit LPA did not observe any deficiencies.

Exit interview conducted with Jolanda Cartridge, Client Care Coordinator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
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