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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881331
Report Date: 07/20/2022
Date Signed: 07/20/2022 10:37:53 AM

Document Has Been Signed on 07/20/2022 10:37 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:ERICA B INDEPENDENT LIVING FACILITYFACILITY NUMBER:
331881331
ADMINISTRATOR:JOHNSON, LA SUNEAFACILITY TYPE:
735
ADDRESS:3656 GINGER STTELEPHONE:
(818) 818-1817
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 0DATE:
07/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Lasunea Johnson, AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an announced pre-licensing inspection to the facility to complete the pre-licensing inspection and Comp III. LPA arrived at the facility at 08:54 AM and was met with Administrator La Sunea Johnson. Administrator Johnson accompanied LPA on a tour of the inside and outside of the facility. Licensee Ericka Graham-Bullock was inside the facility upon inspection.

Currently there are no residents in care. The facility is a four bedroom, three bathroom home. The facility has a family room, living room, dining room and kitchen. Per the approved fire clearance, the licensee is approved for 6 ambulatory residents. All bedrooms are furnished with bed, night stand, dressers and have adequate lighting for residents use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The water temperature was tested and measured between 105.1 to 105.7 degrees Fahrenheit. The smoke alarms and carbon monoxide alarm were tested and are in operating order. LPA observed three fully charged fire extinguishers with one present in the kitchen area, another in the living area, and another upstairs in a common area. The kitchen was observed to have dishes, silverware and pots and pans. There were no knives present at time of visit; however, the knives will be stored with the medications in a locked cabinet. The chemicals are stored in a locked laundry room.

The backyard was observed to be fully fenced with an unlocked gate and plenty of shade via two umbrella's over picnic tables.

LPA found all facility features to be in compliance and in line with Title 22 Regulations.

An exit interview was conducted and a copy of this report was reviewed with and provided to Administrator Johnson.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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