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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320440
Report Date: 08/29/2024
Date Signed: 08/29/2024 12:40:10 PM

Document Has Been Signed on 08/29/2024 12:40 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:D.A. FAMILY HOMEFACILITY NUMBER:
198320440
ADMINISTRATOR/
DIRECTOR:		LOVELY, PAULAFACILITY TYPE:
740
ADDRESS:2911 5TH AVETELEPHONE:
(323) 309-6460
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY: 3CENSUS: 0DATE:
08/29/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:56 AM
MET WITH:Rodrick BarnettTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On August 29, 2024 at 10:00am, Licensing Program Analyst (LPA), Deborah Lee conducted an announced visit to the facility for the purpose of conducting a pre-licensing evaluation. An application was submitted to CCLD on 3/13/2024 for opening a new facility for a Residential Care Facility for the Elderly (RCFE) to serve residents 60 and over. 3 Non-ambulatory, 1 may be bedridden. LPA met with Rodrick Barnett, Applicant Paula Lovely Administrator and explained the purpose of today’s visit and together toured the physical plant(inside and outside).

Overview of Facility:

Facility is a single story home located in a residential neighborhood. Property sit in back of a triplex property. There are resident bedrooms, 1 bathrooms, living/dinning room combo, laundry room located off of the kitchen area. There is a detached garage for storage space. The client bedrooms easily accommodate the client's furnishings.

Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility.

Living room is fully furnished with 1 sofa and 2 chairs, 4 seated dinning table, and mounted TV.


Bedrooms Residents: Bedroom #1 have working lights, new blinds and working windows with bars that has an operable release device and will be occupied by 1 residents.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: D.A. FAMILY HOME
FACILITY NUMBER: 198320440
VISIT DATE: 08/29/2024
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Bedrooms Residents: Bedrooms# 2 have working lights and adequate bedding. This room will be a shared room.

Bathrooms: Bathroom is located off of the living room area and has a working toilet, wash basins and shower, LPAs observed it to be clean, safe, and sanitary.

Linens & Hygiene Supplies: Are located in the a cabinet in the laundry room. Has adequated linens and hygiene supplies.

Facility has a lanline phone for emergencies. Fire Extinguisher is fully functioning/charged and is located in Kitchen by the stove. LPA observed all required post.

LPA observed an area where centrally stored medications will be kept. It is locked and will be inaccessible to residents. LPA observed a first aid kit with required items

Smoke Detectors: Facility has 3 smoke detectors/carbon monoxide detectors. Tested and operable at time of visit.



Appliances: LPA observed all kitchen appliances and washer and dryer in working order. The residence is equipped with heat and air conditioning.

All toxin will be locket and inaccessible to resident. Water temperature tested at 110 degrees F.

All staff files will be locked in a cabinet located in laundry area.

Component III: Conducted during today’s Pre-Licensing visit. No corrections needed at this time.

An exit interview was conducted, and a copy of this report has been furnished to the applicant.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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