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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600215
Report Date: 08/25/2023
Date Signed: 10/02/2023 11:02:46 AM

Document Has Been Signed on 10/02/2023 11:02 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
EL SEGUNDO ASC, 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: 6DATE:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:DSP-Lynda McCulloughTIME COMPLETED:
02:47 PM
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On 08/25/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit, LPA met with DSP-Lynda McCullough as the purpose of today’s visit was explained. The facility is licensed to serve 7 developmentally disabled residents (age 18-59), current census is 6. Residents are linked to the South Central Regional Center, all (6) residents are Ambulatory.

The home is located in a residential area and consist of a two-story structure in an apartment complex, apartments "C" and "D". Apt. "C” includes only the upstairs, which has 3 shared bedrooms, two bathrooms, Living rooms and a staff office. Apt. "D" includes both the downstairs and upstairs, with the kitchen and dining room located on the lower level, which also has one resident 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 conducted a records review of 2 staff records, 2 resident records and 2 Medication Administration Records, LPA did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 07/31/23, 4 fire extinguishers fully charged, carbon monoxide detectors observed, smoke detectors are operational. Landline was observed.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F..

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit no discrepancies were cited. Exit interview conducted with DSP-Lynda McCullough , and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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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