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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603711
Report Date: 07/05/2024
Date Signed: 07/05/2024 09:24:59 AM

Document Has Been Signed on 07/05/2024 09:24 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HERITAGE HOME ARFFACILITY NUMBER:
198603711
ADMINISTRATOR/
DIRECTOR:
GREENE, MIKOLFACILITY TYPE:
735
ADDRESS:8909 HOLMES AVETELEPHONE:
(323) 537-8172
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY: 4CENSUS: 0DATE:
07/05/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:04 AM
MET WITH:Applicant Mikol GreeneTIME VISIT/
INSPECTION COMPLETED:
09:40 AM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a pre-licensing visit. LPA met with applicant Mikol Greene. An initial 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 fire clearance has been approved for four (4) Ambulatory Clients. This property has never been licensed. The physical plant was toured with the applicant. Component III was conducted with applicant.

The facility is in a residential area and is a one-story family home. There are two (2) client bedrooms both bedrooms are shared, one (1) bathroom, living room, dining room, kitchen office/laundry room, front yard, and back yard. LPA conducted the tour with Mikol Greene and observed the following: Smoke detectors were observed in common areas and in each client’s bedroom. There are 2 carbon monoxide detectors in hallway and living room. Client’s bedrooms were observed to have required furniture such as bed frames, dressers, chairs, lamps, and sufficient closet space. The required bedding was also observed. The home has one (1) bathroom and was clean and sanitary. The water temperate was tested and measured at 119.2 degrees, which is within the required 105-120 degrees. There is a fire extinguisher in living room. All appliances in kitchen were observed to be clean and operational. The sharp knives are located in the kitchen drawer that is inaccessible to clients. Cleaning supplies and chemicals are stored in a locked cabinet in kitchen cabinet. Medications are locked in a cabinet in kitchen. Laundry/office was clean and clear of obstruction. The garage is detached from home and used for storage. The backyard has a shaded area with patio furniture. There is a garden area for clients. The home does not have a pool or any large bodies of water. The home has all required posters. There are no cameras inside the home. No records were reviewed since the home has never been licensed. Per California Code of Regulations, Title 22, the facility meets the physical plant requirements.

Exit interview held and a copy of the report was provided to applicant.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2024
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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