198603187-9-13-2023-11-AS-ARID-CVMVUS-20230913164512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603187
Report Date: 09/13/2023
Date Signed: 09/13/2023 04:45:18 PM

Document Has Been Signed on 09/13/2023 04:45 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:	CEN FAMILY EXTENSIVE CARE I		FACILITY NUMBER:	198603187
ADMINISTRATOR:	BOURNE, VAL		FACILITY TYPE:	735
ADDRESS:	1635 W 66TH ST		TELEPHONE:	(323) 834-0132
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY: 4		CENSUS: 3	DATE:	09/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Ebony Brown		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/13/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Required - 1 Year Annual visit using the new CARE Inspection Tools. Upon arrival at the facility, LPA Richard called the facility and spoke to Licensee/Administrator Ebony Brown and explained the reason for the visit. LPA verified that the facility has an approved Mitigation Plan Report. LPA observed a sanitizing station at the facility entrance; PPE supplies are readily available to staff, and an additional over 30-day supply of PPE is stored in the storage closet; sufficient paper, cleaning, and disinfecting supplies were observed. The administrator stated staff and clients are fully vaccinated and that there are three (3) clients currently in placement. LPA Richard and Licensee Brown toured the entire facility inside and outside grounds. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, kitchen, dining room, three (3) bedrooms, two (2) bathrooms, laundry, and storage area in the garage, patio shaded area, detached two (2) car garage, front and back yard landscape is in good condition at the time of visit. Documents were posted as mandated.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CEN FAMILY EXTENSIVE CARE I	FACILITY NUMBER: 198603187
	VISIT DATE: 09/13/2023

NARRATIVE

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The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client's bedrooms were inspected for, safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with manual. The hot water temperature 114.8F degrees Fahrenheit, a working telephone, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, records of medications are centrally stored and properly locked in the hallway closet with the current record, ample supply of perishable and nonperishable food,and adequate linen supply.

The fire/emergency drill conducted on 07/01/2023. No firearms on the premises, the client's bedroom windows have no sliding window locks with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

There were no deficiencies cited.

Exit interview held and a copy of the report was provided to Licensee Ebony Brown.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC809 (FAS) - (06/04)

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