198601747-6-12-2022-11-AS-SCAS-CFBKC9-20220612074646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601747
Report Date: 06/11/2022
Date Signed: 06/12/2022 07:46:55 AM

Document Has Been Signed on 06/12/2022 07:46 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	D & J ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198601747
ADMINISTRATOR:	JERRHONDA HOLMAN		FACILITY TYPE:	735
ADDRESS:	1609 WEST 165TH STREET		TELEPHONE:	(310) 223-0215
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY:	6	CENSUS: 4	DATE:	06/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:41 PM
MET WITH:	Jerrhonda Holman		TIME COMPLETED:	04:00 PM

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On 06/11/22, at 2:41pm, Licensing Program Analyst (LPA) Susan Campos conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Jerrhonda Holman, and explained the purpose of today’s visit. D &J Adult Residential Facility is an adult residential home, licensed to serve a total of six (6) developmentally disabled adults between the ages of 18-59 and three (3) non-ambulatory and three (3) ambulatory clients. Currently there are four (4) developmentally disabled ambulatory adults in placement. This facility is a level 4I home, vendorized with the South Central Los Angeles Regional Center. The last Fire Drill was conducted on January 14, 2022. D & J Adult Residential Facility is a single story home in a residential neighborhood consisting of: living room, kitchen, dining room, (4) four bedrooms ((1)Staff/ Office room and (3) Client rooms), (2) two bathrooms, laundry room area, attached car garage with a patio area with umbrella and chairs.

The LPA and Ms. Holman toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The facility hot water temperature measured 111.4 degrees Fahrenheit. A comfortable temperature of 75 degrees Fahrenheit was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate.

Evaluation Report Continued on LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: D & J ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198601747
	VISIT DATE: 06/11/2022

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Jerrhonda Holman.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2022

LIC809 (FAS) - (06/04)

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