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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320437
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:32:57 PM

Document Has Been Signed on 03/14/2025 03:32 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PETERS FAMILY HOMEFACILITY NUMBER:
198320437
ADMINISTRATOR/
DIRECTOR:		PETERS, JADESHAFACILITY TYPE:
740
ADDRESS:427 E JAVELIN STTELEPHONE:
(323) 481-8771
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 5CENSUS: 5DATE:
03/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:06 PM
MET WITH:Jadesha PetersTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 3/14/2025, at 1:00pm, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required inspection visit using the new CARE Inspection Tool. LPA met with Jadesha Peters, Administrator, and explained the purpose of today’s visit. The facility is licensed to operate for five (5) ambulatory residents ages 60 and above. The facility is approved for (3) hospice residents. Currently the facility has (5) ambulatory residents. The facilities annual fees are current.

The facility is a single-story home and consists of the following: four (4) resident bedrooms, two (2) bathrooms, living room, kitchen, dining room, back yard with patio and chairs, and an attached garage.

LPA conducted a records review of five (5) residents records, three (3) staff records, and reviewed the facility disaster plan. All resident & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. The fire/emergency drill was completed on 3/04/25. LPA reviewed (5) Resident Medication Administration Records and did not observe any discrepancies at the time of visit. The facilities administrator certificate was current and expires on 3/28/2026. LPA observed that the facility has current liability insurance which expires on 03/03/2026.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space, walls and floors were clean and in good repair, and bed linens, comforters and bath towels were fully stocked. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured between 105.1-118.6F degrees.

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SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PETERS FAMILY HOME
FACILITY NUMBER: 198320437
VISIT DATE: 03/14/2025
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke/Carbon monoxide detectors were observed and operational. LPA observed one (1) fire extinguisher that was fully charged; toxins and knives were locked and inaccessible to residents. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked, first aid manual was up to date. A landline was observed. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have 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 Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

During today’s visit LPA did not observe any deficiencies.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator, Jadesha Peters.

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SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
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