198603558-8-19-2024-28-AS-THEA-D8AQZU-20240819123720

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603558
Report Date: 08/19/2024
Date Signed: 08/19/2024 12:37:57 PM

Document Has Been Signed on 08/19/2024 12:37 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:	CHARM HOUSE II		FACILITY NUMBER:	198603558
ADMINISTRATOR/ DIRECTOR:	CLARKE, CHRISTAL		FACILITY TYPE:	735
ADDRESS:	9570 MAYNE STREET		TELEPHONE:	(323) 403-8268
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 4		CENSUS: 0	DATE:	08/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Jeremy Miller - Director		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

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) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Jeremy Miller (Director) and explained the purpose for today’s visit. The facility is licensed to serve (4) Ambulatory Only Clients Ages 18-59 years. The facility currently has (0) clients.

The facility is a two-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: 1st floor: living room, dining area, kitchen, 1 bedroom, 1 full bath, storage closet, attached garage (with staff office and laundry area), front yard with outdoor activity area. 2nd floor: 3 bedrooms and 2 bathrooms (1 bath is inside master room).

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has PPE supplies and there's an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and were within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet in the garage and are inaccessible to clients and a locked kitchen cabinet under sink. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers was observed and is fully charged (one upstairs and one downstairs).
Operational Requirements: Staff have proper training to meet the needs of the clients in care.
Staffing: There appears to be sufficient staffing at all times in the facility. There are currently no clients at the facility, however, upon placement of clients Director Jeremy confirmed there will be staff to meet the needs. (Continued on LIC809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: CHARM HOUSE II	FACILITY NUMBER: 198603558
	VISIT DATE: 08/19/2024

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
26
27
28
29
30
31
32

Personnel Records-Training: Staff files are maintained in a secure location, within the locked staff office in garage. LPA reviewed 2 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED and sufficient on-going training. Christal Clarke maintains a valid certificate that expires on 10/1/2024. Once more staff come on board Director is aware that all files must have the information above and all training documented in file.
Client Rights-Information: Facility provides telephone landline for the clients, phone was tested during visit and was observed to be operable. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: There are no clients at the facility, however, there is a designated area where client files will be maintained within the locked staff office in garage. Director Jeremy confirmed that they are aware that all the following documents must be within the client files upon admission - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food.
Health Related Service: There are no clients in the facility, however, there is a designated area where medication will be centrally stored (within a locked kitchen cabinet). Director is aware that all medication must be locked, labeled and in their original containers. Director Jeremy also confirmed that once clients are admitted staff that will be assisting with medications will have proper training to do so.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Although there haven't been any drills conducted recently due to no clients at the facility, there is an evacuation plan and once clients are admitted fire drills will be conducted upon first admission and quarterly.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report will be emailed to Director Jeremy Miller.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2