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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603036
Report Date: 08/17/2022
Date Signed: 08/17/2022 06:42:16 PM

Document Has Been Signed on 08/17/2022 06:42 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ALPHA OMEGA IIIFACILITY NUMBER:
198603036
ADMINISTRATOR:HARRIS, YAOUNDEFACILITY TYPE:
735
ADDRESS:3484 OLYMPIAD DRTELEPHONE:
(323) 620-8777
CITY:VIEW PARKSTATE: CAZIP CODE:
90043
CAPACITY: 4CENSUS: 4DATE:
08/17/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:caregiver - Katherine TavaiTIME COMPLETED:
03:58 PM
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On 08/17/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced follow up inspection to the above facility for the purpose of plan of correction visit for deficiencies issued during the 2022 annual visit on 08/16/2022. LPA met with caregiver Katherine Tavai and explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory developmentally disabled adults of between the ages of 18 through 59.

LPA observed the following on 08/17/2022:
1. Water temperature for all bathrooms sinks and kitchen sink measured between 113.2 F to 116.3 F.
2. Cabinet door under the shared bathroom sink was fixed and working properly
3. Light fixture in room #4 was fixed and working properly
4. Administrator certificate was posted and is current
5. See something, say something poster is posted in the facility
6. Lime around the sink in bathroom for room #4 was cleaned.

There are no further deficiencies to be corrected for the 2022 annual conducted on 08/16/2022. Licensee will receive deficiency cleared letters in the mail.

Exit interview conducted with caregiver Katherine Tavai and a copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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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