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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603036
Report Date: 11/12/2024
Date Signed: 11/12/2024 11:23:01 AM

Document Has Been Signed on 11/12/2024 11:23 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ALPHA OMEGA IIIFACILITY NUMBER:
198603036
ADMINISTRATOR/
DIRECTOR:		HARRIS, YAOUNDEFACILITY TYPE:
735
ADDRESS:3484 OLYMPIAD DRTELEPHONE:
(323) 792-4199
CITY:VIEW PARKSTATE: CAZIP CODE:
90043
CAPACITY: 4CENSUS: 3DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:39 AM
MET WITH:Katherine Tavai/Facility StaffTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 11/12/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Katherine Tavai/Facility Staff and explained the purpose of today’s visit. The facility is licensed to operate for (4) (developmentally disabled or Mentally Ill) adults ages 18 through 59. Approved for (4) ambulatory only. Currently, the home has (3) clients. The clients are from South Central Los Angeles Regional Center. (0) Restricted Health Care Conditions, and (0) utilizes postural support or protective devices. Staff to client ratio is (1:2).

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, three (3) bathrooms, living area, a dining area and kitchen. There is an outside patio area in the backyard. The garage is detached.

During the inspection, LPA Iniguez and the facility staff toured both the inside and outside of the facility, inspecting a total of (4) bedrooms and (2) bathrooms. LPA found that the mattresses and box springs were in good condition, there was adequate lighting, and plenty of dresser and closet space. The facility was observed to be clean, sanitary, and in good repair. Additionally, bed linens, comforters, and bath towels were adequately stocked during the visit. The bathrooms were found to be in compliance with Title 22 regulations, the toilets and water faucets worked properly.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ALPHA OMEGA III
FACILITY NUMBER: 198603036
VISIT DATE: 11/12/2024
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The shower was free of mold and mildew, and there was adequate lighting and sufficient toiletries accessible to clients. The water temperature measured between 105°F and 120°F, with the kitchen at 116.4°F and Bathroom #1 at 115.4°F.During the visit, LPA found that the perishable and non-perishable food supply was adequately stocked. The carbon monoxide/smoke detector combo was operational, and fire extinguishers were fully charged. Toxins and knives were securely locked away from clients. Medications were centrally stored and properly locked, ensuring safety. The first aid kit was also found to be fully stocked, ready for any emergency.

LPA conducted a records review of (3) client and (3) staff records; all client and staff records were complete. Clients do not take medications. The facility disaster plan was current and in compliance with Title 22 at the time of the visit.

The last facility disaster drill was on 9/9/24. Facility licensee fees are current. A copy of the Surety Bond was given to LPA during the visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Katherine Tavai/Facility Staff.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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