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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600839
Report Date: 08/08/2024
Date Signed: 08/08/2024 01:19:11 PM

Document Has Been Signed on 08/08/2024 01:19 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SVS - WILMINGTONFACILITY NUMBER:
191600839
ADMINISTRATOR/
DIRECTOR:		SHAWN CROSSFACILITY TYPE:
735
ADDRESS:235 "L" ST.TELEPHONE:
(310) 549-5040
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY: 6CENSUS: 3DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:49 AM
MET WITH:Shawn CrossTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On August 8, 2024, Licensing Program Analyst (LPA) Wendy Gibbs and Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with Staff Keisha Harris RSS I and explained the purpose of this visit. Subsequently, Administrator Shawn Cross joined the visit. The facility is licensed for 6 adults 18-59 ambulatory residents and 2 age approved waivers. Currently, there are three (3) residents in placement.

Structure 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, kitchen, laundry area, attached garage, shaded area, indoor/outdoor activity areas.

Physical Plant LPAs and Administrator Shawn Cross toured the facility inside and outside. LPA observed There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 110 degrees F. A comfortable temperature of 75 degrees F. was maintained in the facility.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SVS - WILMINGTON
FACILITY NUMBER: 191600839
VISIT DATE: 08/08/2024
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Bedrooms LPA inspected all (3) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, nightstands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom. The water temperature measured 110-degrees Fahrenheit. The Staff bathroom was observed to be clean. The toilet and faucets are operational. Both bathrooms were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets.

Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, and additional freezer. LPA observed an ample supply of cutleries, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in locked drawers in the kitchen and are inaccessible to residents.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SVS - WILMINGTON
FACILITY NUMBER: 191600839
VISIT DATE: 08/08/2024
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 LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods and condiments were labeled with the date when they were opened and date of when they expire. All food was properly stored and labeled. Cleaning products and toxins were secured in a locked cabinet and are inaccessible to residents. The water temperature measured 110-degrees Fahrenheit.

Common Rooms In the living room, LPA observed, ample seating for all residents and space to accommodate residents. The facility is maintained at a comfortable temperature.

Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed an operational Carbon Monoxide detector in the hallway. LPA observed 2 fully charged fire extinguisher mounted on the wall, last serviced on April 2024. LPA inspected the First Aid kit and found it contained an ample supply of required items and a manual. LPA observed the required posting in the facility. LPA observed all exits to be clear and easily accessible. There are no firearms or ammunition stored on the premises.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SVS - WILMINGTON
FACILITY NUMBER: 191600839
VISIT DATE: 08/08/2024
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Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet in the kitchen/dining area. LPA reviewed three (3) Resident’s medications and matched them to the Medication Administration Record (MARs). 3 out of 3Resident’s MARs and medications are consistent with properly documented records.

Files LPA reviewed three (3) resident files and found the contained all the necessary documentation. LPA reviewed four (4) staff files and found they contained the required documentation, certification, and training. LPA reviewed copies of Client Roster, Staff Roster, Emergency and Disaster Plan (LIC610E), Activity Schedule, Meal Menu posted.

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper towels, cleaning, and disinfecting supplies were observed. All staff were wearing a face covering. LPA observed required postings throughout the facility. LPAs observed that the licensing fees are current.

LPA did not observe any deficiencies during the time of visit.

An exit interview was conducted with Administrator Shawn Cross and a copy of this report was provided.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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