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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603664
Report Date: 04/28/2023
Date Signed: 04/28/2023 12:11:15 PM

Document Has Been Signed on 04/28/2023 12:11 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:CAROUSEL COMPLETE CAREFACILITY NUMBER:
198603664
ADMINISTRATOR:JOHNSON, SOPHESIASFACILITY TYPE:
735
ADDRESS:700 E. 80TH STREETTELEPHONE:
(310) 720-7165
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 6CENSUS: 6DATE:
04/28/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Sophesias JohnsonTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted an announced pre-licensed visit and met with Applicant Sophesias Johnson for the purpose of conducting a Pre-Licensing Inspection / Component III visit. The facility has an approved fire clearance to be licensed to serve four (6) ambulatory only adult clients Ages 18-59. Property has a back ADU, that is not a part of facility and will remain locked and inaccessible to clients. The facility is a single story home: 3 bedrooms, 2 1/2 bathrooms, dining/ living room, backyard and ADU home located in Los Angeles,CA.

The physical plant was toured inside and out alongside with Sophesias Johnson. Pre-Licensed Inspection Tool was used.
The following was observed/inspected

· Bedrooms are equipped with one bed, night-stand, chair, sufficient lighting, appropriate closet and drawer space. Facility is licensed for 6, however, there are only 5 beds.


· All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Mattresses and bedsprings are in good repair.
· Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.
· Sufficient supply of linens available to permit weekly changing and are stored in storage cabinet.
· Sufficient personal hygiene supply available.
· Laundry machine (wash/dryer) observed.
· The 2 ½ bathrooms have working toilets/wash basin, and shower. Shower is missing non-slip mat.
· There are enough bath towels, hand towels and wash cloths for all clients.
· Smoke Detectors and Carbon monoxide detectors are interconnected approved in the Fire Clearance.
· Two (2) Fire extinguishers observed and charged.
· Cleaning solutions and sharps are securely locked in kitchen and inaccessible to clients
· Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher are in working condition, clean and sanitary.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CAROUSEL COMPLETE CARE
FACILITY NUMBER: 198603664
VISIT DATE: 04/28/2023
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· Food Menu Samples observed.
· Sufficient dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair
· The facility is licensed for 6 but only have 4 dining chairs
· There is a designated space for Medications to be locked and inaccessible to clients..
· Client and Staff files will be stored and locked in designated file cabinet.
· First Aid Kits observed with manual.
· Physical plant is in good repair.
· Building and grounds are free from hazards.
· Window screens are in good condition.
· There is a shaded area provided in the backyard to accommodate clients, no bodies of water observed.
· Hot water temperature measured between 112.6 and 117.1 F and is within Title 22 regulation.
· The residence is equipped with central air and heating, temperature remains at comfortable temp.
· Facility cell phone line operable, facility number: 310-720-7156.
· Variety of activity supplies for clients observed.
· Licensee reports no guns or weapons in the home.

Component III was also completed at the time of the visit and all required documents for Licensing were discussed. Facility did not meet the physical plant requirements/ inspection as required per California Code of Regulations Title 22 Division 6.


The following Corrections need to be made prior to clearing the physical plant:

· Additional Dining Seating for the capacity of 6 in dining


· Licensed for 6 beds but only 5 beds, bedroom 3 where 1 bed is located does not appear to have sufficient space to accommodate 2nd bed, 2nd lamp and 2nd dresser.
· Non- slip shower mat in bathroom

An exit interview was conducted and a copy of this report has been furnished to the Applicants. Accordingly, 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, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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