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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603544
Report Date: 02/11/2022
Date Signed: 02/11/2022 02:59:33 PM

Document Has Been Signed on 02/11/2022 02:59 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:LOVE BEYOND WORDS RESIDENTIAL CAREFACILITY NUMBER:
198603544
ADMINISTRATOR:PIPER, TONIEFACILITY TYPE:
735
ADDRESS:14516 TACUBA DRIVETELEPHONE:
(310) 650-0545
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 0DATE:
02/11/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Applicants Debra Ballou-Harding and Tonie PiperTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an announced visit with Applicants Debra Ballou-Harding and Tonie Piper. The purpose of the visit was to conduct the Pre-Licensing visit.

An application was submitted to CCLD on 1/26/2022, for Change of Location and Capacity of an Adult Residential Facility. The requested capacity of 6 clients, (6) ambulatory, (0) non-ambulatory of which (0) may be bedridden.

Structure/Physical Plant:
The facility is a single story home located in a residential area and contains the following: family room, dining room, Den, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for sharps, (3) client rooms, (2) bathrooms ; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A connected garage inaccessible to clients for storage. A washer and dryer. The residence is equipped with central air and heating.

Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Client Rooms: Bedrooms #1-#3 are for (2) ambulatory clients each. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: Bathroom #1 and #2 have a working toilet, wash basin, shower, and nonskid mats. Safety bars were observed in the shower and around the toilet. Bathroom#2 is a private bathroom for bedroom #3 Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed.

Continued in LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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: LOVE BEYOND WORDS RESIDENTIAL CARE
FACILITY NUMBER: 198603544
VISIT DATE: 02/11/2022
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Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There are (2) cordless phones for client use. Fire Extinguisher 1 and 2 fully charged and up to date. Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates were observed. Knives, cutlery and other sharps inaccessible to clients are kept in a locked cabinet. Smoke Detectors & Fire Extinguishers: Detectors and dual Fire alarms and carbon monoxide detectors and are interconnected. All tested and working. (2) Fire extinguishers observed and up to date. Appliances: Stove burners and oven operational. Microwave, washer, and dryer are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured at 117 degrees throughout the facility Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to clients. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and first aid manual which is available for staff use. Clients & Staff Files: Facility has a locked cabinet for clients and staff files. Files were observed. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 1/21/2022.

Component III:
Component III was conducted with Applicants Debra Ballou-Harding and Tonie Piper.

There are no corrections needed and the physical plant of the facility is cleared.

An exit interview was conducted and a copy of this report has been furnished to Tonie Piper. Pre-licensing is complete and there are no deficiencies. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC809 (FAS) - (06/04)
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