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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591729
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:42:21 PM

Document Has Been Signed on 01/27/2023 03:42 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:C.M.A.FACILITY NUMBER:
191591729
ADMINISTRATOR:AMARSINGHE, SWARNAFACILITY TYPE:
735
ADDRESS:18432 GRIDLEY RD.TELEPHONE:
(562) 860-2479
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 48CENSUS: 45DATE:
01/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator- SWARNA AMARSINGHETIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted a health and safety check at the above facility in response to a Special Incident Report (SIR) that was submitted to Licensing on 01/26/2023. LPA met with Administrator Swarna Amarsmghe to discuss the purpose of todays visit.

Investigation consisted of the following: LPA Calderon collected residents and staff roster, police report incident #923-01679-1349-144 that occurred on 1/25/23. LPA obtained records of Client #1 (C1) and Client #2 (C2): Client's assessment and history, care coordination plan, physician's report, identification and emergency information, and progress notes.LPA Calderon along side with Swarna toured the physical plant, which consist of a single story buildings: main house, two middle cottages, men's dorms, back unit, a total of twenty-four resident bedrooms, court yard patio, middle patio and backyard. LPA toured all rooms in the main house, cottage 1 and 2, men's dorm, back unit and did not observe any safety concerns. LPA Calderon observed common areas like dinning room/ tv rooms, no concerns observed.

LPA observed the client's in care to identify any signs of neglect, abuse, or other immediate health and safety threats; LPA did not observe any immediate Health and/or Safety concerns. No deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted with the Administrator Swarna Amarsmghe and provided a copy of todays report.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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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