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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603311
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:08:34 PM

Document Has Been Signed on 05/24/2022 01:08 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NURTURE AT ADWENFACILITY NUMBER:
198603311
ADMINISTRATOR:TORRES, PRINCESS W.FACILITY TYPE:
735
ADDRESS:7612 ADWEN STREETTELEPHONE:
(424) 362-6566
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 6CENSUS: 4DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Derry Sandajan, Hiouse Manager TIME COMPLETED:
11:20 AM
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On 5/24/22 at 8:49 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting an annual required inspection. Upon arrival LPA met with Derry Sandajan (House Manager) and explained the reason for the visit.

Facility is licensed to serve 6 clients between the ages 18-59. Approved for 6 ambulatory clients. The facility is a single-story building in a residential area, with a commercial kitchen, dining room, living room, 3 bedrooms,2 bathrooms, office space, backyard with ample shaded area and a garage. There are no large bodies of water. Fire extinguisher observed in office space. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.

LPAs discussed infection control practices with House manager, toured the facility inside and out, reviewed food supply, staff files, and resident medications.

Report continued on 809c

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NURTURE AT ADWEN
FACILITY NUMBER: 198603311
VISIT DATE: 05/24/2022
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Bedrooms 1-3 have the required furniture including: bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. All sharps are locked and secured. Passageways and exits are free of obstruction. The front and backyard are well maintained. Bathrooms 1-2 are clean with the required signs. The hot water temperature measured at 105.3- 120.2 degrees F. The facility temperature at the time of the visit was comfortable. There is sufficient lighting throughout the facility. Medications reviewed for all residents and it appears to be given as prescribed. Staff file reviewed to have required background and health screening. Infection control signs posted throughout the facility and LPA observed 30 days’ supply of PPE’s located in the garage. Last disaster drill conducted March 2nd, 2022. Administrator certificate # 6040711735 expire 06/08/2022.

Due to technical difficulties LPA could not final print at the facility. LPA was able to provide a copy of this report to house manager.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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