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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530009
Report Date: 04/29/2022
Date Signed: 04/29/2022 10:36:53 AM

Document Has Been Signed on 04/29/2022 10:36 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
, CA 92507
FACILITY NAME:L AND T RESIDENTIALFACILITY NUMBER:
365530009
ADMINISTRATOR:SHERROD-JORDAN, TOMMY L.FACILITY TYPE:
735
ADDRESS:6259 FILLMORE AVETELEPHONE:
(909) 875-1975
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 3DATE:
04/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Tommy Sherrod-JordanTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted an announced pre-licensing inspection. LPA met with Licensee and Administrator, Tommy Sherrod-Jordan. This facility is currently licensed as L and T Residential, license number 366424106. Today's pre-licensing inspection is for a change of ownership application with three (3) clients in care. The fire clearance was approved on 4/14/2022 for six (6) ambulatory residents.

The facility has a total of four client bedrooms, one staff room/office, two bathrooms, a kitchen/dining area, a living room, a family room, laundry room, backyard, and attached garage. LPA and Licensee toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, chairs, and lighting.
Client Bathrooms: The bathroom appliances were operating in safe and sanitary conditions. LPA observed night lights in the bathroom.
Kitchen and Dining Areas: Utensils and dishware were observed to be in good condition for current clients use. Kitchen appliances and countertop were free of debris and in good repair. There was also a meal menu available for review.
Common Sitting Areas: There is adequate seating in the common areas. The facility had a supply of activities for the clients.
Laundry Room: The area is secured by a door from the kitchen. A locked cabinet was observed for knives/sharps, cleaning supplies/toxins, and hygiene items for clients.
Backyard: There is a covered area with seating. All passageways were free from obstruction.

LPA and Licensee observed a locked closet that serves as centralized storage for clients and staff files, medications, and personal protective equipment (PPE). ***LIC 809C***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: L AND T RESIDENTIAL
FACILITY NUMBER: 365530009
VISIT DATE: 04/29/2022
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A charged fire extinguisher and operating smoke detectors and carbon monoxide alarms were observed at the time of visit. LPA observed required postings including the visitation polices, emergency/disaster plans, and personal rights. The facility was equipped with a complete first aid kit and manual. The facility had a working telephone for client use. The water temperature was tested and observed to be between 105-108 degrees Fahrenheit.

LPA observed that the physical plant is clean, in good repair, and appear to be hazard-free during today's visit. LPA has determined that the facility is meeting operational requirements for current clients. LPA completed COMP III with Licensee at the conclusion of the inspection. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Tommy Sherrod-Jordan.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC809 (FAS) - (06/04)
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