198603426-5-20-2021-28-AS-NWEY-C37RT2-20210520131735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603426
Report Date: 05/06/2021
Date Signed: 05/20/2021 01:18:47 PM

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:	J AND C HOUSE OF LOVE II		FACILITY NUMBER:	198603426
ADMINISTRATOR:	SMITH, CHANTE		FACILITY TYPE:	740
ADDRESS:	15218 WILDER AVENUE		TELEPHONE:	(562) 706-2128
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 4	DATE:	05/06/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	Chante Smith		TIME COMPLETED:	10:17 AM

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	Licensing Program Analyst (LPA) Nicol Wesley conducted an announced Pre licensing tele-inspection. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre licensing inspection was conducted via a Microsoft Team video with applicant designee Chante Smith. A virtual tour of the entire physical plant was completed, that included: living room, kitchen, dining room, 5 bedrooms(bedroom #3 designated for staff), 2 bathrooms(1 in bedroom #3), garage, laundry room(washer and dryer), and a back yard area with an area for shade(table/chairs/umbrella). The facility will be licensed to serve 6 non ambulatory residents ages 60 and above. The facility phone number is 562 219 7402. There are currently 4 residents in care. The water temperature measured 123 degrees F. Medications, medication records, and first aid kit with manual are centrally stored in a locked cabinet. Toxins, detergents, and sharps, are stored in a locked cabinet underneath the kitchen sink. Handicap ramps are located at the front entrance, hallway #2, exit door in bedroom #2, and exit door in bedroom #5. Bathroom #1 contained grab bars and non skid strips in the shower. Night lights were observed to be in the hallways. Linen, towels, resident's personal kits, and PPE supplies, were observed in the cabinets in hallway #1. The smoke detectors/carbon monoxide detectors were tested and are operable. 1 fully charged fire extinguisher is located on the wall next to the kitchen. LPA's observed adequate perishable and non perishable food items, as well as an additional refrigerator and deep freezer located in the garage. Component III Orientation with Applicant designee is waived as the applicant designee has completed it in the past. LPA observed all the required posting as mandated. Administrator Certificate(RCFE) for Chante M. Wise #6027733740 expires 10/08/2021. Continued on LIC 809C.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: J AND C HOUSE OF LOVE II	FACILITY NUMBER: 198603426
	VISIT DATE: 05/06/2021

NARRATIVE

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The following items are needed prior to licensure:

Water temperature to be adjusted to measure between 105-120 degrees F. Water temperature to be tested for 7 days/submit the temperature log to LPA Wesley by 05/13/21.
Enough bath towels, hand towels, and wash cloths for each consumer(will be licensed for a total of 4, these items cannot be commonly shared).
Chest of drawer for bedroom #2.
Remove the excess cable cord in bedroom #4.
FYI: No clients bedroom shall be used as a public or general passageway to another room, bath or toilet.
CAB(Centralized Application Bureau) to finalize application.

The applicant designee Chante Smith will contact LPA Wesley when the items have been corrected/obtained. If the applicant requires additional questions/concerns regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

Exit interview was conducted with Applicant designee Chante Smith and a copy was provided via email to obtain a signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC809 (FAS) - (06/04)

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