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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603558
Report Date: 05/25/2022
Date Signed: 05/25/2022 01:01:26 PM

Document Has Been Signed on 05/25/2022 01:01 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:CHARM HOUSE IIFACILITY NUMBER:
198603558
ADMINISTRATOR:CLARKE, CHRISTALFACILITY TYPE:
735
ADDRESS:9570 MAYNE STREETTELEPHONE:
(323) 403-8268
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 0DATE:
05/25/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Jeremy Miller
Administrator Christal Clarke		TIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Nune Margaryan and Ashley Calderon conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPAs meet with Licensee Jeremy Miller and Administrator Christal Clarke who assist with the visit.

An application was received on 02/01/2022, for Initial License # 198603558 Adult Resident Facility to serve 4 ambulatory and clients in the age range of 18 through 59.
The facility is a two story house located in a residential area which consist of a living room, kitchen, dining area, 4 bedrooms ( 1 - first floor and 3 - second floor.) office, laundry room are located in the attached garage. There is covered sitting area at the front of the house. The client bedrooms are spacious and will easily accommodate the client's furnishings. Passageways, walkways, driveway are free of obstructions. Front, back and side areas are free of hazards. Bedrooms have all the required furniture such as beds, chairs, dressers, drawers, night stands and overhead lighting. Bathrooms have working toilets, wash basins, stand up shower. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket. Emergency Phone Numbers, Exit Plan & Menu are posted & readily available for review in the office. Fire Extinguishers are observed in the kitchen and upstairs hallway.
Telephone system is a land line located in the living room. Dishes, cups and flat ware are stored in the kitchen, inspected and in good repair. Knives, cutlery and the sharp kitchen utensils are stored in a locked kitchen cabinets. No food supply observed in the kitchen. Kitchen appliances are clean and functioning properly. Smoke Detectors and Carbon monoxide detector are operational. Chemicals will be stored under the kitchen sink in a locked cabinet and in the locked storage room. Water temperature tested at 110.4 to 112.6 degrees.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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: CHARM HOUSE II
FACILITY NUMBER: 198603558
VISIT DATE: 05/25/2022
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A first aid kit has been inspected and consist the following: tweezers, scissors, antiseptic, bandages, gauze which are stored in the kitchen cabinet available for staff use but inaccessible to clients. Applicant will be handling cash resources of clients. Cash resources will be locked and stored in the office with P & I Ledger, accessible to designated staff. LPAs didn't observed any activity supplies, recreational materials or games for the client's use. There are no Pool/Jacuzzi & Pets on the premises. Fire Clearance was approved on 04/01//22.

LPAs used the inspection tool and the pre-licensing checklist for ARF during this visit.


Component III: Waved: Licensee is currently operating under License # 198603027 of the same category.


The following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of Nune Margaryan by June 1, 2022.

Mattress pad is needed for client bed in the bedroom #2.
Replace the window screen in the bathroom on the second floor.
Thermometer and first aid manual are missing.
Activity supplies, recreational materials and games needed for the clients.



Exit interview was conducted with applicant and a copy of this report was provided Licensee Jeremy Miller.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC809 (FAS) - (06/04)
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