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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603603
Report Date: 08/30/2024
Date Signed: 08/30/2024 01:09:49 PM

Document Has Been Signed on 08/30/2024 01:09 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:K & J ADULT RESIDENTIAL IIFACILITY NUMBER:
198603603
ADMINISTRATOR/
DIRECTOR:		HOLMAN, JERRHONDAFACILITY TYPE:
735
ADDRESS:8737 GUATEMALA AVETELEPHONE:
(562) 225-1038
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 4CENSUS: 4DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Administrator Shenesia GladneyTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. Administrator Shenesia Gladney at approximately 10:15 AM and explained reason for visit.

Facility is licensed to serve four (4) ambulatory developmentally disabled adults, ages 18-59. This single-story home contains office area, kitchen, living/dining room, staff break room, storage room, 2 client rooms, 2 bathrooms, front yard, backyard, and detached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke/ carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has two (2) fully charged fire extinguishers which is kept in kitchen and hallway. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. LPA observed an insufficient supply of 2 days perishable food deficiency cited. LPA observed enough 7 days non-perishable foods in the kitchen. There is an extra freezer in garage with frozen food. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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Document Has Been Signed on 08/30/2024 01:09 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/30/2024 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: K & J ADULT RESIDENTIAL II
FACILITY NUMBER: 198603603

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above facility did not have enough fresh foods for two days which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Administrator agrees to go to store for fresh fruit and vegetables and other foods and provide pictures and receipts to email to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: K & J ADULT RESIDENTIAL II
FACILITY NUMBER: 198603603
VISIT DATE: 08/30/2024
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted August 07, 2024. Infectious control plan was reviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Administrator Shenesia Gladney.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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