198603099-9-2-2021-11-AS-ASOO-C62VD8-20210819162020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603099
Report Date: 08/19/2021
Date Signed: 09/02/2021 09:09:34 AM

Document Has Been Signed on 09/02/2021 09:09 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:	AMAZING EFFORTS VI LLC		FACILITY NUMBER:	198603099
ADMINISTRATOR:	HENSON, TAMARA		FACILITY TYPE:	735
ADDRESS:	548 W BENNETT ST		TELEPHONE:	(310) 933-8486
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 4		CENSUS: 4	DATE:	08/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ivette Gomez, Administrator		TIME COMPLETED:	04:00 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 Ivette Gomez, Administrator and the purpose of today’s visit was explained.

There are currently (4) four Regional Center consumers in placement. All (4) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 3 bathrooms, family room/office, lounge, living room, kitchen, dining room, shaded area, laundry room, indoor and outdoor activity area, music room, vegetable garden, 5 horse stables converted into storage areas, and a detached garage (game room.)

LPA and Administrator toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1 - 4 are occupied by clients and contain the mandated furniture. The (3) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector are in compliance, inter-connected and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 staff file is current, 1 resident file is current along with medications. The water temperature is at 114 degrees. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, 1 fire extinguishers is 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: 08/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMAZING EFFORTS VI LLC	FACILITY NUMBER: 198603099
	VISIT DATE: 08/19/2021

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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 the bathrooms and additional sanitation supplies in a locked cabinet located in the garage. LPA observed staff and clients wearing masks, an isolation room and required postings throughout the facility. The facility has an approved Mitigation plan. Visitors are logged and checked. The client’s temperatures are checked and logged 2x a day. All 4 clients are vaccinated (32 staff - 25 vaccinated.)

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.

An exit interview conducted with Ivette Gomez, Administrator and copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

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