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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602912
Report Date: 07/05/2023
Date Signed: 07/05/2023 04:52:42 PM

Document Has Been Signed on 07/05/2023 04:52 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:ADE-EMMANUEL ADULT RESIDENTIAL FACILITY IIFACILITY NUMBER:
198602912
ADMINISTRATOR:OSISANYA, ADEBAYOFACILITY TYPE:
735
ADDRESS:2114 EAST 111TH STREETTELEPHONE:
(323) 519-5360
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY: 4CENSUS: 4DATE:
07/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Osisanya AdebayoTIME COMPLETED:
03:30 PM
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On 07/05/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Osisanya Adebayo as the purpose of today’s visit was explained. The facility is licensed to serve four (4) developmentally disabled adults ages 18-59. Residents are linked to the South-Central Los Angeles Regional center.

The facility is a single-story structure located in a residential neighborhood and consists of the following: The home consists of 4 Bedrooms and 2 Bathrooms, living area, dining area, kitchen, an outdoor laundry area an outdoor shaded activity area and a detached garage that serves as the administrators office.

LPA conducted a records review of two (2) staff record, one (1) resident records and one (1) Medication Administration Records, LPA did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 05/5/23, two (2) fire extinguishers fully charged, carbon monoxide detectors observed, smoke detectors are operational, and a landline was observed.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F..

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit no discrepancies were cited, exit interview conducted with Administrator Osisanya Adebayo, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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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