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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601508
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:12:22 PM

Document Has Been Signed on 06/14/2021 03:12 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HOLMAN'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601508
ADMINISTRATOR:KASHSAI GOODWINFACILITY TYPE:
735
ADDRESS:1552 EAST 118TH PLACETELEPHONE:
(323) 567-0745
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY: 4CENSUS: 4DATE:
06/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Jerhonda HolmanTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Jerhonda Holman, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve (4) Developmentally- Disabled adults which may include (2) ambulatory and (2) non ambulatory ages 18 years - 59 years. There are currently (4) South Central Regional Center clients in placement. One (1) out of four (4) clients is non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms, 2 bathrooms, living room, , dining room, kitchen with eating area, and laundry room/ office.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms was found to be within Title 22 regulations and were clean and operational. The water temperature measured 111.0 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff were wearing face coverings, and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed. Exit interview held. A copy of the report was provided to Jerhonda Holman.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2021
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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