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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603619
Report Date: 01/31/2023
Date Signed: 01/31/2023 02:01:06 PM

Document Has Been Signed on 01/31/2023 02:01 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:DAJAH'S HOME BFACILITY NUMBER:
198603619
ADMINISTRATOR:ROBERTSON, MILESFACILITY TYPE:
735
ADDRESS:11624 TIGRINA AVETELEPHONE:
(562) 755-7464
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 4CENSUS: 0DATE:
01/31/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jesse Quezada TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA), Angelica Rea, conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. Also present were Administrator, Miles Robertson, Malvin Dunklin, care staff, and Diana Gonzalez, DSP. An application was submitted to CCLD on 05/05/2022, for Initial license for a Adult Residential Facility to serve age range 18 through 59. The requested capacity is for 4 ambulatory residents. Licensee, Jesse Quezada stated that his family member(s) are currently residing in the home, because he did not want the home to be vacant.

Structure:
The facility is a single story house and located in a residential neighborhood area. Facility is a 4 bedrooms, 2 bathrooms, kitchen, living room, and dining area. The client bedrooms are spacious and will easily accommodate the client's furnishings. The yard has a covered and shaded area with a table and chairs. LPA observed children's toys in the yard.

Bedrooms Residents:
There is one bed in each client's bedroom. Each bedroom has one beds, one chairs, one night stand, one dresser, one closet and overhead lighting. Currently the bedrooms have personal belongings, which belong to licensee's family members.

Bathrooms:
All bathrooms have a working toilet, wash basin and shower.

Water Temperature:
The hot water temperature measured at 147.8 degrees F.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DAJAH'S HOME B
FACILITY NUMBER: 198603619
VISIT DATE: 01/31/2023
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LPA determined the facility is not ready for licensure due to currently having occupants. LPA advised that facility must be ready to receive clients.. LPA will return to the facility at a later date, once current occupants have vacated the facility.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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