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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320164
Report Date: 05/25/2021
Date Signed: 05/25/2021 11:44:33 AM

Document Has Been Signed on 05/25/2021 11:44 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:PAPA JOE'S HANDSFACILITY NUMBER:
198320164
ADMINISTRATOR:SWAFFORD, RASHIMERFACILITY TYPE:
740
ADDRESS:216 E. 137TH. ST.TELEPHONE:
(310) 562-7694
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 6CENSUS: 0DATE:
05/25/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Rashimer SwaffordTIME COMPLETED:
12:00 PM
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On May 25, 2021 at 8:00 a.m., Licensing Program Analyst Ulysses Coronel conducted an announced visit to the facility for purpose of a pre-licensing evaluation.

An application was submitted to CCLD on 05/04/2021, for Initial license for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for 6 ambulatory only residents.

Structure: The facility is a 4 bedroom, 3 bathroom, single story house with a 2 car attached garage. The home has a gas fire place in the living room with a metal screen cover, and is inaccessible to clients. There is a large, covered patio area. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a back yard with a patio for shade. The passageways, walkways, driveways, steps and patios are free from obstructions. The front, back and side areas of free of hazards, such as ladders, gardening tools, motorized equipment.

Bedrooms # All 4 resident bedrooms are for ambulatory residents only. Each bedroom has a beds, chairs, night stand, and lamps in addition to overhead lighting. There are dressers with drawers and closets, which comply with the requirement of 8 cubic feet of drawer space for each resident.

Bedrooms Staff: Bedroom # No bedroom designated for awake-staff.

Bathrooms: All bathrooms have a working toilet, wash basin, bathtub/shower. All bathtubs, showers and toilets have grab bars and operate properly. All bathtubs have nonskid mats.

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in linen closet in bedroom hallway.

Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review in the living room area. Fire Extinguisher located near at end of Bedroom#4 and Bathroom mounted on wall, a second extinguisher is located under the kitchen sink. The facilities telephone system is, land line.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2021
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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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: PAPA JOE'S HANDS
FACILITY NUMBER: 198320164
VISIT DATE: 05/25/2021
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Food Service: Dishes, cups and flats are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the sink. Food supply adequate stored in kitchen and garage, consists of the following: 2 days supply on perishable and one weeks supply on nonperishable foods like meats, fruits, vegetables, rice, pastas, cereals, soups and sauces.

Smoke Detectors: Smoke detectors are installed in all 4 bedrooms and Hallway are Electrical & connected. Smoke and Carbon Monoxide detector located in hallway and is operational.

Appliances: Stove burners, oven, microwave, washer, and dryer working. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled.

Toxins: Locked/stored in kitchen cabinet.

Water Temperature: Tested at 11.7 degrees F.

Medications, First-Aid Kit & Book: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in office area, available for staff use but inaccessible to clients.

Clients & Staff Files: Applicant will be handling cash resources of clients and has a surety bond for a million dollars, cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked cabinet and the section has been inspected along with the available records present. located in the office area in the living room.

Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.

Pool/Jacuzzi & Pets: None.

Fire clearance: Fire Clearance for up to 6 ambulatory only residents was approved on 04/28/2021.

Pre-licensing Checklist: Completed by licensee and reviewed by LPA.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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: PAPA JOE'S HANDS
FACILITY NUMBER: 198320164
VISIT DATE: 05/25/2021
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During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by 06/01/2021. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction

1. LPA observed that there were only a total of 4 resident beds. Applicant stated that they initially requested for a total capacity of up to 4 residents. Applicant will coordinate with Centralized Applications Bureau regarding the request changes in capacity.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to the applicant.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
LIC809 (FAS) - (06/04)
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