198603611-1-24-2023-28-AS-BTAO-CNDRWL-20230124122320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603611
Report Date: 01/24/2023
Date Signed: 01/24/2023 12:23:35 PM

Document Has Been Signed on 01/24/2023 12:23 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:	ERH 1		FACILITY NUMBER:	198603611
ADMINISTRATOR:	YOUNGBLOOD, MARLISHA		FACILITY TYPE:	735
ADDRESS:	10501 PARMELEE AVE,		TELEPHONE:	(323) 608-9919
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90002
CAPACITY: 6		CENSUS: 3	DATE:	01/24/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	MARLISHA YOUNGBLOOD, Applicant		TIME COMPLETED:	12:30 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) Tao conducted an announced pre-licensing inspection. LPA met Marlisha Youngblood, licensee applicant/administrator. This is a change of ownership applying for Adult Residential Facility to serve for ages 18 to 59 years clients. The previous license # was 198603032, ERH 1. The facility has a requested capacity of six (6) and located in a residential neighborhood. There were two (2) caregivers on duty and three (3) clients at the time of visit. Administrator certificate is current and expiration date 3/16/2023. Fire clearance: Fire clearance was approved for two (2) ambulatory clients, four (4) non-ambulatory clients and zero (0) bedridden clients. Fire clearance was granted on 12/20/22. Structure: The facility is a single-family house. There are four (4) client bedrooms, two (2) bathrooms, kitchen, dining area near the kitchen, living room with a TV, laundry room at the side yard, and backyard with shaded area. Bedrooms for clients: Bedrooms have a night stand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. Bathrooms: Toilet, wash basin, and shower in bathroom are operable. Bedrooms for non ambulatory clients are accommodated. Grab bars are maintained for bathtub. (-Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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: ERH 1	FACILITY NUMBER: 198603611
	VISIT DATE: 01/24/2023

NARRATIVE

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Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning. Stove is operable. Water temperature tested at 111.5 degrees Fahrenheit in kitchen sink which was in compliance with the regulation

Smoke Detectors:
Smoke detectors and carbon monoxide detectors are dual and hard wired. Detectors are located in hallways and each room. They are operable.

Appliances:
Stove burners, oven, microwave, washer, and dryer are working. Refrigerator in the kitchen and has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

Linens & Hygiene Supplies:
The required linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are sufficient. Adequate supply of linen, wash cloths and towels are observed.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan is posted near the entrance. Emergency phone numbers, exit plan, Covid signages and posters are posted.

Food Service:
Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to clients. Food supply is sufficient. The food supply consists of two days of perishable and two weeks of non-perishable.

Medications, First-Aid Kit & Book:
Medication cabinet is locked and inaccessible to clients. First aid kit is fully stock with a First Aid manual from American red cross.
(-Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: ERH 1	FACILITY NUMBER: 198603611
	VISIT DATE: 01/24/2023

NARRATIVE

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Menu and phone:
Menus are available for review.
Free landline telephone is available for clients’ use and operable.

Fire extinguishers:
One fire extinguisher is located in the kitchen which is mounted on wall. Another fire extinguisher is located in the garage. They are fully charged. The last service is done on 12/20/22.

Clients & Staff Files:
Applicant will be handling cash resources of clients and has a surety bond. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients are stored in a locked cabinet and the section has been inspected along with the available records at the locked cabinet.

Reading Material, Games, Equipment & Materials:
The facility has recreational materials available for clients’ use and commensurate with the plan of operation.
Pool:
No bodies of water located at the facility.

Outdoor activity area in backyard:

Outdoor activity area is furnished with chairs and table, located under a shaded area and in compliance with the regulation.

Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to clients.

Conclusion:

No issues were observed.

(-Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: ERH 1	FACILITY NUMBER: 198603611
	VISIT DATE: 01/24/2023

NARRATIVE

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Exit:

Component III was conducted during this visit.

An exit interview was conducted and a copy of this report was provided to applicant, Marlisha Youngblood. 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, applicant has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC809 (FAS) - (06/04)

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