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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320318
Report Date: 07/11/2024
Date Signed: 08/02/2024 09:09:21 AM

Document Has Been Signed on 08/02/2024 09:09 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MARTHA'S HOUSE LLCFACILITY NUMBER:
198320318
ADMINISTRATOR/
DIRECTOR:		HYMES, SHARINAFACILITY TYPE:
740
ADDRESS:2422 E. 113 ST.TELEPHONE:
(323) 381-0025
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY: 4CENSUS: 0DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Licensee/Administrator - Sharina HymesTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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On 08/02/2024 at around 8:00 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator Sharina Hymes. LPA explained the purpose of the visit and was accompanied by Administrator inside and outside the facility during this inspection.

This facility is licensed to serve 4 adults ages 55 and above.
A total of 0 residents are currently residing in this facility.
A total of 0 staff are currently in the facility.

The facility is a one-story house located in a residential street. The home consists of 2 resident bedrooms, 1 bathroom, 1 living room, 1 kitchen, 1 detached garage, and 1 backyard patio area with shaded seating.

Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are security bars on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Documents are posted as mandated. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MARTHA'S HOUSE LLC
FACILITY NUMBER: 198320318
VISIT DATE: 07/11/2024
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2 out of 2 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit.

No deficiencies are being cited based on LPA observation in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted and a copy of this report was left with the Administrator.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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