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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601934
Report Date: 12/14/2022
Date Signed: 09/05/2023 01:44:44 PM

Document Has Been Signed on 09/05/2023 01:44 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CBG HOME INC.FACILITY NUMBER:
198601934
ADMINISTRATOR:NEEKOLE GLASPIEFACILITY TYPE:
735
ADDRESS:13413 S. VAN NESS AVENUETELEPHONE:
(310) 327-2531
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 4DATE:
12/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Clay Hope and Barhea TheadoreTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with staff Clay Hope and Barhea Theadore and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report.

LPA Bunker verified that the administrator is present at the property 20+ hours per week, and all current staff are fingerprint cleared and associated with the facility. The facility's annual fees are current. The facility currently has five (5) ambulatory, and one (1) non-ambulatory Westside Regional Center (WRC) consumers in placement.

The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a single-story family home located in a residential neighborhood. LPA Bunker and staff made a complete tour of the facility which consisted of: Living room, dining area, kitchen, breakfast area, den, office area, 4 bedrooms, 2 bathrooms, laundry room, storage room, attached garage, patio/shaded area, indoor/outdoor activity areas.
See continued LIC809-C page #2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CBG HOME INC.
FACILITY NUMBER: 198601934
VISIT DATE: 12/14/2022
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Continued LIC809-C page #2

Documents were posted as mandated on the wall in the office area and the laundry room. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The facility bathrooms are operational. The first aid kit is fully stocked with a manual, the hot water temperature was measured at 120 degrees Fahrenheit, the telephone is working, the smoke, carbon monoxide detectors, and sprinklers were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in a cabinet next to the office area, and records are current, the last facility fire/emergency drill was conducted on November 10, 2022. No firearms on the premises, the client's bedroom windows had no sliding window lock with thumbscrew, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

Mr. Hope states staff was given training on dependent adult and elder abuse reporting.

LPA Bunker provided staff Clay Hope with a copy of the LIC809 and LIC809-C

There were no deficiencies cited.

An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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