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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602907
Report Date: 04/10/2023
Date Signed: 04/10/2023 03:05:30 PM

Document Has Been Signed on 04/10/2023 03:05 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:SAPPHIRE ADULT RESIDENTIAL HOMEFACILITY NUMBER:
198602907
ADMINISTRATOR:EZIWHOU, CHIMENEMFACILITY TYPE:
735
ADDRESS:1306 S CENTRAL AVENUETELEPHONE:
(415) 374-0060
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 5CENSUS: 4DATE:
04/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:EZIWHOU, CHIMENEMTIME COMPLETED:
03:00 PM
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On 04/10/2023 at 9:30 am, Licensing Program Analyst (LPA)/ Antonine Richard conducted an unannounced annual required visit using the Care Inspection Tool. LPA met with Administrator Chimenem Eziwhou, and explained the purpose of today’s visit. The facility is licensed to serve 5 clients ages 18 to 59 years old, 5 ambulatory clients, of which one non-ambulatory. This facility is a level 4I home. Vendorized by the South Central Los Angeles Regional Center. The facility is a single story residential home located in a residential neighborhood. The home consists of the following: 5 bedrooms (4 client bedrooms and 1 office), 2.5 bathrooms, dining room, kitchen, living room, laundry room, backyard with umbrella, table and chairs, and detached garage. There were no bodies of water or obstructions on the premises.

The LPA and Administrator. toured the physical plant. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured 106.9F degrees Fahrenheit. A comfortable temperature of 75 degrees Fahrenheit was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. The facility fire extinguisher is fully charged. Smoke detectors and carbon monoxide are operable. A review of Medication Administration Records (MAR) was observed to be maintained in order and accurate. Documents are posted as mandated by Title 22 regulations. Emergency disaster plans are posted by near exits. The last fire drill was conducted January 27, 2023.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SAPPHIRE ADULT RESIDENTIAL HOME
FACILITY NUMBER: 198602907
VISIT DATE: 04/10/2023
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During the visit, LPA observed the facility's infection control practices. ( LPA) observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. The LPA observed staff were wearing face coverings, LPA observed the facility has a 30-days supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. Facility files were reviewed. Files are kept in a locked cabinet. Client files were randomly chosen for review. Clients' medical assessments are completed and include TB information. Clients have complete needs and services plans on file. Staff have criminal record clearances and proof of in service training. Staff files have complete health screenings and current first aid certificates.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Chimenem Eziwhou.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC809 (FAS) - (06/04)
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