331880644-3-23-2023-18-AS-CNWE-CQ7Q7L-20230323115520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880644
Report Date: 03/23/2023
Date Signed: 03/23/2023 11:55:29 AM

Document Has Been Signed on 03/23/2023 11:55 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CRENSHAW TOWN AND COUNTRY GUEST HOME 1 LLC		FACILITY NUMBER:	331880644
ADMINISTRATOR:	REAVES, ARTAGO		FACILITY TYPE:	735
ADDRESS:	2346 FIREBRAND AVE		TELEPHONE:	(909) 475-9075
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY: 4		CENSUS: 2	DATE:	03/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Artago Reaves, Administrator		TIME COMPLETED:	12:00 PM

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On March 23, 2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry into the facility by Administrator, Artago Reaves. Artago Reaves was informed of the purpose of visit. At the time of visit there was 2 staff and 2 residents present. LPA toured the facility inside and out with Artago Reaves.

Tour included:

Kitchen: LPA toured the kitchen and observed food is stored in a safe and healthful manner. LPA observed Utensils and dishware are sufficient for the number of clients in care. The refrigerator and stove are in working order. Refrigerator was large enough to accommodate required perishable food. Sharps are stored in a locked kitchen cabinet, available only to authorized individuals. Trash can have tight-fitting lid. Dishwasher is used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 44.1 degrees Fahrenheit and Freezer was measures at -14 degrees Fahrenheit.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 72 degrees Fahrenheit. LPA inspected the fire extinguisher located in the dining room and found it to be in compliance and record to be up to date.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications: LPA observed medications were labeled and stored in separate bins inside of a locked medication cabinet in the kitchen and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CRENSHAW TOWN AND COUNTRY GUEST HOME 1 LLC	FACILITY NUMBER: 331880644
	VISIT DATE: 03/23/2023

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Continued from LIC809

Bathroom: LPA toured hall bathroom and observed bathroom to be clean and equipped with grab bar and non-slip mats. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 109 degrees Fahrenheit.

Bedroom: LPA toured three out of #3 residents’ bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. Resident #1 bedroom has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 116 degrees Fahrenheit.

Laundry room and Garage; LPA toured the laundry room and observed laundry room to be clean. Washing machine and dryer are all in good repair. Cleaning solutions were observed to be adequately secured in a cabinet. LPA tour the garage and observed garage to be clean.

Backyard: LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Two #2 staff and #2 residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 11/24/2023

Interview: Two #2 staff and #2 clients present was interviewed.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Artago Reaves.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

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