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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601934
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:28:44 PM

Document Has Been Signed on 12/11/2023 03:28 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:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kim CooperTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Kim Cooper, Administrator and the purpose of today’s visit was explained. There are currently (4) residents in placement.

The facility is a single-story structure located in a residential neighborhood. It consists of Living room, dining area, kitchen, breakfast area, den, 4 bedrooms, 2 bathrooms, laundry room, attached garage, patio/shaded area.

LPA Shirley and Kim walked through the kitchen and all appliances were in good working order. Knives were locked and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 113.5 degrees Fahrenheit.

All bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly. The showers were free of mildew and mold.

LPA Shirley and Kim walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the dining room area. This facility is in good condition.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Kim Cooper, Administrator and a hard copy of report provided

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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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