<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591729
Report Date: 09/08/2023
Date Signed: 09/08/2023 02:28:04 PM

Document Has Been Signed on 09/08/2023 02:28 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: 47DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Swarna AmarsingheTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/8/2023 at 9:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with the Administrator / Swarna Amarsinghe who assisted with the visit. The facility is licensed to serve for a capacity of forty eight (48) clients ages 18-59, Ambulatory only. The Administrator Certificate expires on 3/24/2024 #6014768735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the carbon monoxide detectors, reviewed (5) staff files, (10) client files, medications, and medication administration records for (10) clients.

The facility is operating within the scope of it's license. The facility consists of 6 separate buildings. Building 1 includes a living room, dining room, office, kitchen, six bedrooms (shared) and two bathrooms. Building 2 includes bedrooms (shared) and 2 bathrooms. Building 3 includes 1 bedroom (shared), 1 bathroom, laundry room and storage room. Building 4 includes 2 bedrooms and 1 bathroom. Building 5/Office includes 10 bedrooms (shared) and 5 bathrooms. There is one vacancy in room #12. Building 6/Trailer includes 3 bedrooms, 2 bathrooms, a living room/lounge and a kitchen (without a stove). No cooking is done in the trailer, but the area is used by ABC adult school.

LPA toured the physical plant with the Administrator. and observed all client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. In building #4 Room #6 the closet door was broken. In building #6 Room #1 the client dresser drawers were broken. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were fire extinguishers fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured. LPA observed underneath the kitchen sink was unlocked and contained cleaning agents and toxins. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: C.M.A.
FACILITY NUMBER: 191591729
VISIT DATE: 09/08/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use.

LPA will return and review staff training, water temperature, fire panel and finalize care tools. Citations will be issued upon completion of the care tools. Exit interview conducted with Administrator Swarna Amarsinghe and a copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2