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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320318
Report Date: 11/15/2022
Date Signed: 11/18/2022 09:51:50 AM

Document Has Been Signed on 11/18/2022 09:51 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MARTHA'S HOUSE LLCFACILITY NUMBER:
198320318
ADMINISTRATOR:HYMES, SHARINAFACILITY TYPE:
740
ADDRESS:2422 E. 113 ST.TELEPHONE:
(323) 381-0025
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY: 4CENSUS: DATE:
11/15/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sharina HymesTIME COMPLETED:
09:51 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type: Initial
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: Sharina Hymes (applicant/licensee, administrator)
Interview Method: Telephone interview

On 11/18/22, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements/CPMB associations & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Susan Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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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