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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603537
Report Date: 04/22/2022
Date Signed: 04/22/2022 01:38:26 PM

Document Has Been Signed on 04/22/2022 01:38 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A PLACE TO HEALFACILITY NUMBER:
198603537
ADMINISTRATOR:HIGGINBOTHAM, LAKECIAFACILITY TYPE:
772
ADDRESS:137 E 104TH STREETTELEPHONE:
(323) 202-8432
CITY:LOS ANGELESSTATE: CAZIP CODE:
90003
CAPACITY: 6CENSUS: DATE:
04/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Licensee Lakecia HigginbothamTIME COMPLETED:
01:46 PM
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Licensing Program Analysts (LPA) Alberto Lopez conducted a Pre-Licensing Visit at the proposed facility site. LPA met with Licensee/Administrator Lakecia Higginbotham and discussed the purpose of the visit.

10:26 am A tour of the physical plant was conducted with Licensee/Administrator Lakecia Higginbotham. The Facility consist of one two story structure with three shared bedrooms, one dining room, two full client’s restrooms, one staff restroom, one living room, one storage room, one isolation room, one staff office with medication locked up, and one laundry room, The structure has independent hot water delivery system and is equipped with climate control including air conditioning. Medications and Facility files and records will be secured in staff office. Three fire extinguishers were observed and are fully charged. The facility has fire clearance for 6 ambulatory clients only. Carbon monoxide/fire detectors were observed and tested in each bedroom and throughout the facility.
There is one spare room that will be used as activity room for clients.

BEDROOMS: There are three shared bedrooms designated for client use. All bedrooms are currently furnished for double occupancy with beds including mattress and box springs, dressers, nightstands and lamps. Each bedroom has a closet. Each room has an operable fire alarm and was tested
BATHROOM: There are two full bathrooms available for client use. One for males and one for females. The male bathroom has 1 shower, one toilet, and one sink. The female bathroom has 1 shower, 1 toilets and 1 sink. All are all functional. The hot water was tested in all three bathrooms and kitchen and measured from 114.3 F to 117.0 degrees F. Which is within the regulations of 105-120 degrees F. The facets for the bathrooms all function. Toilets are operable
LIVING ROOM: There is a living room area that is fully furnished with one table, sofa enough to sit all Clients, and 55” TV. The area is adequate to accommodate 6 clients.

Reading Material, Games, Equipment:. NONE

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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: A PLACE TO HEAL
FACILITY NUMBER: 198603537
VISIT DATE: 04/22/2022
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FOOD: There was not a enough nonperishable food for 7 days.

Linens & Hygiene Supplies. Extra Blankets and entire bedding sets on order. Emergency Phone Numbers, Exit Plan & Menu: Posted. Smoke/carbon monoxide Detectors are hardwired and working. Appliances: Stove burners, microwave, washer, and dryer working. Knives: are locked and inaccessible to clients.

Component III conducted at the Pre-Licensing visit

The following are required prior to licensing:

1: Licensee will purchase 7 days of nonperishable food and send proof to LPA.

2: Licensee will purchase additional blankets and comforters and send proof to LPA.

3: Licensee will purchase reading Materials, games and equipment for activity room and send proof to LPA.

A copy of this report was provided to the Applicant/Administrator and an exit interview conducted.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
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