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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603603
Report Date: 09/28/2022
Date Signed: 09/28/2022 08:48:18 AM

Document Has Been Signed on 09/28/2022 08:48 AM - 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:K & J ADULT RESIDENTIAL IIFACILITY NUMBER:
198603603
ADMINISTRATOR:HOLMAN, JERRHONDAFACILITY TYPE:
735
ADDRESS:8737 GUATEMALA AVETELEPHONE:
(562) 225-1038
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 4CENSUS: 4DATE:
09/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Shenesia Gladney - Lead SupervisorTIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an announced Pre-Licensing visit. LPA met with Shenesia Gladney (Lead Supervisor) and explained the reason for the visit. A change of corporation name application was submitted to Community Care Licensing Department (CCLD) for an Adult Residential Facility to serve 4 ambulatory clients in the age range of 18 through 59.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the office area, kitchen, family/dining room, staff office/break room, storage room, 2 client rooms, 2 bathrooms, front yard, backyard, and detached garage.

LPA Mora conducted the tour with Shenesia Gladney 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 and refrigerator in the garage. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked in a kitchen cabinet. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a cabinet near the family/dining room. Client files are kept in the family/dining room. Staff files are kept locked in the office area. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 108.2 degrees F and 105.3 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors and carbon monoxides were observed throughout the facility 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.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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: K & J ADULT RESIDENTIAL II
FACILITY NUMBER: 198603603
VISIT DATE: 09/28/2022
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LPA reviewed medication for 4 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 4 clients and 3 staff. No issues were found with the files. LPA observed administrator certificate for Jerrhonda Holman - 6004044735 with an expiration date of 11/29/2023.

Facility has 30 days supplies of Personal Protective Equipment in the storage room. 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.

No outstanding or pending items were observed by the LPA requiring additional pre-licensing visits. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.



Exit interview conducted and a copy of this report was provided to the Lead Supervisor.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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