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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603232
Report Date: 09/30/2021
Date Signed: 09/30/2021 03:09:54 PM

Document Has Been Signed on 09/30/2021 03:09 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:AMAZING EFFORTS VIII, LLCFACILITY NUMBER:
198603232
ADMINISTRATOR:HENSON, TAMARAFACILITY TYPE:
735
ADDRESS:414 N. PEARL AVETELEPHONE:
(323) 236-8523
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY: 4CENSUS: 3DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Ivette GomezTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Ivette Gomez, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve 4 clients (age 18-59) if which 2 may be non-ambulatory. There are currently 3 South Central Regional Center clients in placement. All 3 clients are ambulatory. The facility consists of 4 bedrooms, 2 bathrooms, living room, dining area and kitchen. There is a backyard with a covered patio for shade.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 115.1F and 118.5 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During todays visit LPA observed that staffs S1, S2 and S3's criminal record clearances were not associated to this facility's license. During todays visit LPA observed that the licensee has not reported the changes in administrators as per Title 22 Regulation requirments. During todays visit LPA observed that the gate leading from the backyard to the front yard was locked.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, and required postings throughout the facility.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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 6
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 VIII, LLC
FACILITY NUMBER: 198603232
VISIT DATE: 09/30/2021
NARRATIVE
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LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were deficiencies observed, Title 22 Division 6 Chapters 1 and 6 are being citedplease see LIC809D.

An exit interview held and plans of corrections were developed. A copy of the report and appeals rights was provided to Ivette Gomez, Administrator.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/30/2021 03:09 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 09/30/2021 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMAZING EFFORTS VIII, LLC
FACILITY NUMBER: 198603232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above with 3 out 3 of staff present during todays visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2021
Plan of Correction
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The licensee agreed to submit all of Amazing Efforts VIII, LLC's staffs Criminal Record Clearance Transfer Requests and attachments to the department by sending them via US Mail and emailing copies to janae.hammond@dss.ca.gov by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/30/2021 03:09 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 09/30/2021 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMAZING EFFORTS VIII, LLC
FACILITY NUMBER: 198603232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above the gate leading from the backyard to the front yard was locked with a pad lock which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2021
Plan of Correction
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The administrator removed the pad lock during todays visit and agreed to conduct a staff training to ensure future compliance with the section cited above. Proof of correstion is due by POC due date.
Type B
Section Cited
CCR
85061(b)(1-3)
85061 Reporting Requirements
(b) The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator. Such notification shall include the following:
(1) Name, and residence and mailing addresses of the new administrator.
(2) Date he/she assumed his/her position.
(3) Description of his/her background and qualifications, including documentation of required education and certification.
(A) A photocopy of the documentation shall be permitted.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above for administrator Ivette Gomez' which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2021
Plan of Correction
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The licensee agreed to submit the administrator packet as required by this section to LPA Coronel by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
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