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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603472
Report Date: 12/01/2022
Date Signed: 12/01/2022 02:38:41 PM

Document Has Been Signed on 12/01/2022 02:38 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TERN BAY HOMEFACILITY NUMBER:
198603472
ADMINISTRATOR:BOATNER, VERRETTAFACILITY TYPE:
735
ADDRESS:2213 TERN BAY LANETELEPHONE:
(424) 338-3054
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 3CENSUS: 0DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Verretta Boatner - AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Verretta Boatner (Administrator) and explained the reason for the visit. The facility is licensed to serve 3 non-ambulatory clients ages 18-59. Facility currently has no clients.

A tour of the single-story facility included the 3 client bedrooms, 2 bathrooms, living room, dining area, kitchen, staff area, front yard, backyard and attached garage. LPA Mora conducted the tour with Verretta and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps and cleaning chemicals were observed locked under the kitchen sink. The First Aid kit is kept mounted on the hallway wall and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in each bedroom closet. Dining and living room have sufficient lighting and sitting area. Medications and client and staff files will be kept locked in a hallway closet. All bedrooms have all required furniture, lighting, and bedding. The bathrooms were observed with shower mats and required grab bars for non-ambulatory clients. The water temperature was tested in the both bathrooms and measured at 118.7 degrees F and 119.4 degrees F, which is within the required 105-120 degrees F. Fire extinguishers were observed in the hallways and are fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and in each room and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA did not review client medication or files due to facility not having any clients. There are no staff currently working at this facility due to having no clients. LPA observed the administrator certificate for Verretta Boatner - 6050652735that expires on 01/24/23.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TERN BAY HOME
FACILITY NUMBER: 198603472
VISIT DATE: 12/01/2022
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Facility has 30 days supplies of Personal Protective Equipment in a living room cabinet. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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