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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600215
Report Date: 03/25/2024
Date Signed: 03/25/2024 11:03:01 AM

Document Has Been Signed on 03/25/2024 11:03 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:DSP Lynda McCulloughTIME COMPLETED:
11:12 AM
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On 03/25/24 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 clients (age 18-59), current census is 6. clients are linked to the South Central Regional Center, all (6) residents are Ambulatory. DSP provided with upcoming facility fees info.

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 (2) staff offices. Apt. "D" includes both the downstairs and upstairs, with the kitchen, pantry 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, staff refrigerator, an additional freezer, a storage area for hygiene supplies and toxins.

LPA conducted a records review of 2 staff records, 2 client 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 02/01/2024, 4 fire extinguishers fully charged, carbon monoxide detectors observed, smoke detectors are operational. Land line was observed.

All client 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, showers are free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Knifes were observed to be locked and inaccessible to clients. There are no firearms nor bodies of water on the premises. 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: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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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