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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602903
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:11:04 PM

Document Has Been Signed on 06/07/2022 03:11 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FAITH ADULT RESIDENTIAL HOME #2FACILITY NUMBER:
198602903
ADMINISTRATOR:STEWART-ABE, ADESHOLAFACILITY TYPE:
735
ADDRESS:1134 EAST 104TH STREETTELEPHONE:
(818) 200-3874
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY: 4CENSUS: 3DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adeshola Stewart-AbeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control Visit to the above facility. LPA was met by Administrator Adeshola Stewart-Abe and the purpose of today’s visit was explained.

The home is licensed to serve up to (4) four ambulatory clients ages 18 - 59. There are currently (3) clients in the facility. and all (3) clients are ambulatory. The facility consists of : Living room, dining room, kitchen, 3 client bedrooms, 2 bathrooms, laundry room, office and a garage. Physical plant inside and outside is in good repair.

LPA and Administrator Stewart-Abe toured the entire facility inside and out. Documents are posted as mandated. Client bedrooms contain the mandated furniture. The bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Medications and files are current and kept in a locked file cabinet. Food supply was adequate for 2-day perishable and 7-day non-perishable. Hot water temperature is 115 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, Exit, walkways and/or passageways, are free of debris and/or hazards.

The following were observed/inspected:

  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms bathrooms and hallways.
  • Clients are able to use their private rooms as a designated isolation room if a COVID-19 positive case should arise.

(Continued on LIC809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH ADULT RESIDENTIAL HOME #2
FACILITY NUMBER: 198602903
VISIT DATE: 06/07/2022
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  • 30 day supply of medication for clients
  • Facility has an adequate amount of PPE and facility has enough PPE for 2 months.
  • Clients were socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Hand Sanitizer: Available throughout the facility for client use.
  • The clients temperature's are checked and logged once a day.
  • Staff temperatures are checked and logged once a day at beginning of their shift.
  • Staff and clients are tested weekly for COVID-19.

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

An exit interview conducted with Administrator Adeshola Stewart-Abe, Administrator and copy of report provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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