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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600839
Report Date: 07/20/2023
Date Signed: 07/24/2023 08:58:25 AM

Document Has Been Signed on 07/24/2023 08:58 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SVS - WILMINGTONFACILITY NUMBER:
191600839
ADMINISTRATOR:SHAWN CROSSFACILITY TYPE:
735
ADDRESS:235 "L" ST.TELEPHONE:
(310) 549-5040
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY: 6CENSUS: 3DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Shawn Cross TIME COMPLETED:
12:45 PM
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On 07/20/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Shawn Cross as the purpose of today’s visit was explained. The facility is an ARF licensed for four (3) ambulatory residents, residents are linked to the Harbor Regional center.

LPA conducted a records review of 2 staff record, 1 resident record, 1 Medication Administration Record, and 1 P&I ledger, 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 06/19/23, 2 fire extinguishers fully charged, carbon monoxide detectors observed, smoke detectors are operational, and a landline was observed.

The facility is a single-story, 3-bedrooms, 2- ½ bathroom home located in a residential neighborhood. It consists of the following: Living room, dining area, den with a staff work area, kitchen, laundry area, attached garage, shaded area, indoor/outdoor activity areas.



LPA and staff toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. 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.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. During today’s visit no discrepancies were cited.
An exit interview was conducted, and a copy of this report was provided to Shawn Cross, Administrator.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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