<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602903
Report Date: 05/16/2024
Date Signed: 05/16/2024 11:15:34 AM

Document Has Been Signed on 05/16/2024 11:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FAITH ADULT RESIDENTIAL HOME #2FACILITY NUMBER:
198602903
ADMINISTRATOR/
DIRECTOR:		STEWART-ABE, ADESHOLAFACILITY TYPE:
735
ADDRESS:1134 EAST 104TH STREETTELEPHONE:
(818) 200-3874
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY: 4CENSUS: 3DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Administrator,Adeshola Stewart-AbeTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by DSP staff Olayinka Apetuje and explained the purpose of the visit. Administrator Adeshola Stewart-Abe was notified. Administrator has taken R#3 to day program and will arrive afterwards, LPA Vaid conducted a physical tour of the facility with Staff Apetuje. There are three (3) ambulatory developmentally disabled clients who reside in the home. The facility is an Adult Residential Facility (ARF) vendored by the South Central Los Angeles Regional Center.

12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station at the entrance of the facility. The facility does have an Infection Control Plan and the administrator explained that she will send it to LPA following the inspection.

Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood that is licensed for four clients between the ages of 18 - 59. It consists of 3 client bedrooms, an office, a living room, dining room, a kitchen, 2 (two) bathrooms of which the non-private restroom and private restroom in the shared bedroom were tested and water temperature is within 105 degrees F to 120 degrees F, and a backyard area with covered area,At 9 free of obstacles and debris. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher that is kept in the kitchen of the house. Cleaning supplies and toxic substances are inaccessible to clients.

Continued on LIC 809C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH ADULT RESIDENTIAL HOME #2
FACILITY NUMBER: 198602903
VISIT DATE: 05/16/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for four (4) clients between the ages of 18 - 59. Care and supervision to meet the clients needs was observed.
Staffing: A total of four (4) full-time staff members provide care and supervision to the clients.
Personnel Records/Staff Training: Administrator has a valid certificate which is effective through 8/22/2023. Four (4) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information: Physician orders were reviewed in client files.
Client Records/Incident Reports: Three (3) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication records.
Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Three (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place in the dining room and are not accessible to clients in care. Medications are given according to Physician directions.
Incident Medical and Dental: All clients have a Needs and Services Plan. Staff training was on file.
Disaster Preparedness, and Emergency Intervention: A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. An emergency drill was conducted on 05/01/2024.
Emergency Intervention: No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5