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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600215
Report Date: 07/15/2022
Date Signed: 07/15/2022 05:20:24 PM

Document Has Been Signed on 07/15/2022 05:20 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WITHERS ADULT RESIDENTIAL FACILITY #3FACILITY NUMBER:
191600215
ADMINISTRATOR:PEGGIE M. WITHERSFACILITY TYPE:
735
ADDRESS:1306 E. PECK ST APT. DTELEPHONE:
(310) 604-0069
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY: 7CENSUS: 7DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lynda McCullough, Direct Support ProfessionalTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced priority annual required visit with a primary focus on infection control measures. LPA was met by Lynda McCullough, Direct Support Professional and the purpose of today’s visit was explained. The facility is licensed to serve 7 developmentally disabled clients (age 18-59).

There are currently (7) South Central Regional Center clients in placement and is designated as a Level III home. All (7) clients are Ambulatory. There were two clients present in the home. The home is located in a residential area within the city limits of Compton and consist of a two-story structure in an apartment complex, with the facility being towards the rear of the complex consist and takes up two apartments "C" and "D". Apt. "C” includes only the upstairs, which has 3 shared bedrooms, two bathrooms, Living rooms and the facility office. Apt. "D" includes both the downstairs and upstairs, with the kitchen and dining room located on the lower level, which also has one client bedroom, staff bedroom and one bathroom. The facility has a garage that consist of washer/dryer unit, fridge and storage area with PPE’s and hygiene supplies.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 112F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Three Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WITHERS ADULT RESIDENTIAL FACILITY #3
FACILITY NUMBER: 191600215
VISIT DATE: 07/15/2022
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has 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 Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to McCullough.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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