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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530023
Report Date: 08/09/2022
Date Signed: 08/09/2022 09:42:52 AM

Document Has Been Signed on 08/09/2022 09:42 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:COMPASSION HOME 1FACILITY NUMBER:
335530023
ADMINISTRATOR:WRIGHT-ILORI, ROSEFACILITY TYPE:
740
ADDRESS:825 CHALLENGE AVENUETELEPHONE:
(614) 394-5674
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 0DATE:
08/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Rose Wright-Ilori, Samson IloriTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-licensing evaluation. LPA Goldenberg observed the following:

Structure: Facility was a single story house with five (5) resident bedrooms, 2.5 bathrooms, living room, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: Each resident bedroom were adequately furnished with bed, chair, closets, appropriate linens, adequate lighting, and an operational smoke alarm and emergency lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, toiletries, and rails and non-slip mats.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.

Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: COMPASSION HOME 1
FACILITY NUMBER: 335530023
VISIT DATE: 08/09/2022
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Linens and Hygiene Supplies: An adequate supply of linens was available.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.

Garage: Laundry area with washer and dryer in place. Laundry detergents and cleaning solutions were secured behind a locked cabinet door. Garage was organized and free of obstructions. There was a recreational leisure area set up client use.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and clients rights are posted. PPE supply is ample. COVID screening station and postings are located at the entry. Sign in procedures are in place.

General items: Smoke detectors and carbon monoxide detectors were tested and operational. LPA observed a facility phone and it was verified to be operational.

COMPONENT III was reviewed during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time.
This report was reviewed with the applicant and a copy is being provided.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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