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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600793
Report Date: 08/24/2022
Date Signed: 08/24/2022 02:14:34 PM

Document Has Been Signed on 08/24/2022 02:14 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SIMPSON FAMILY HOMEFACILITY NUMBER:
191600793
ADMINISTRATOR:SIMPSON, ESTELLFACILITY TYPE:
735
ADDRESS:18430 COLTMAN AVETELEPHONE:
(310) 324-8973
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 2DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Vicki SimpsonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual visit, with an emphasis on infection control, on 08/24/2022. Upon arriving at the facility, LPA met with Vicki Simpson the administrator, and explained the purpose of this visit. LPA was granted access and allowed to enter the facility to conduct the inspection. At the entry point she took my temperature and asked the required COVID-19 screening questions before we continued.

The facility is licensed to serve four (4) ambulatory high functional clients ages 18-59. The facilities annual fees are current during today’s visit. Clients are referred by the South-Central Los Angeles Regional Center. Currently, there are only two clients at the facility.

LPA toured the two-story facility with the administrator. While on the tour the administrator was adding new COVID signage to the facility. The facility consists of two (2) client bedrooms (downstairs), staff bedroom (downstairs), guest room (upstairs), three (3) bathrooms (one bathroom located in staff room and one bathroom located in guest room), living room, kitchen, dining area, attached garage, front porch, laundry room, indoor patio, and backyard. Centrally stored medications are locked in a medicine cabinet in the patio area. Disinfectants, cleaning solutions, detergent, and toxins are inaccessible to clients and locked in the laundry room.

Evaluation Report continues LIC 809C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SIMPSON FAMILY HOME
FACILITY NUMBER: 191600793
VISIT DATE: 08/24/2022
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There is more than a one-week supply of nonperishable and perishable foods at the facility. The facility is maintained at a comfortable temperature. Hot water temperature was measured at 106.2 degrees Fahrenheit. There are working lights in each room to ensure safety and comfort for all clients in the facility. All outdoor and indoor passageways were free of obstruction.

The clients have clean linen which includes blankets/bedspreads, top and bottom sheets, pillowcases, and mattress pads. First aid kit had the required items, along with the manual. The facility has a written emergency disaster plan located in the patio area. The facility has operable smoke/carbon monoxide detectors. LPA observed one (1) fire extinguisher located in the kitchen last serviced on 05/2021. No firearms are stored at facility and no bodies of water were present. The facility is in good repair.

During the visit, LPA observed the following to be complying: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD

No deficiencies were cited during this visit. Exit interview conducted and a copy of this report was provided to the administrator Vicki Simpson.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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