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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602958
Report Date: 08/09/2022
Date Signed: 08/12/2022 08:33:06 AM

Document Has Been Signed on 08/12/2022 08:33 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HOME AWAY FROM HOME ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198602958
ADMINISTRATOR:THOMAS, MARKFACILITY TYPE:
735
ADDRESS:2714 WEST 108TH STREETTELEPHONE:
(323) 474-5236
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 3CENSUS: 0DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mark Thomas, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Mark Thomas, Administrator and the purpose of today’s visit was explained.

There are currently (0) Westside Regional Center consumers in placement. There are no clients residing at the facility at this time. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 2 bathrooms, living room/office, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and a detached garage.

LPA and Administrator toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. All 3 bedrooms contain the mandated furniture. The (2) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector comply and operational. No firearms are stored at facility and no bodies of water present. The facility has no clients or staff working at the facility at this time. The water temperature is at 105 degrees. A comfortable temperature is maintained in the facility. No food supply at this time, no linens at this time, sufficient personal hygiene supplies, hazardous toxins and/or items are inaccessible to clients, (1) fire extinguishers are fully charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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 4
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HOME AWAY FROM HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198602958
VISIT DATE: 08/09/2022
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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in all bathrooms and additional sanitation supplies stored in closet.The clients are the isolation rooms and required postings throughout the facility. No trash can with lids, no carts with PPE’s, No fit testing done for staff. The facility has an approved Mitigation plan. Visitors are logged and temperatures checked.

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.

Technical Advisories (TA) issued.



An exit interview conducted with Mark thomas Administrator and copy of report provided.


SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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