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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601265
Report Date: 07/08/2024
Date Signed: 08/09/2024 01:26:42 AM

Document Has Been Signed on 08/09/2024 01:26 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:GARDENA SENIOR CITIZENS DAY CARE CENTERFACILITY NUMBER:
191601265
ADMINISTRATOR/
DIRECTOR:		CHRISTINA THEOBALDFACILITY TYPE:
775
ADDRESS:14517 SO. CRENSHAW BLVD.TELEPHONE:
(310) 217-9550
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 30CENSUS: 8DATE:
07/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:49 PM
MET WITH:Ericka Yamashiro, Nutritionist Services CoordinatorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 7/08/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA met with Nutritionist Services Coordinator, Erika Yamashiro and explained the purpose of today’s visit. The facility is licensed for sixty (30) ambulatory clients of which twenty-four (24) may be non-ambulatory. There are eight (8) clients in attendance today.

The facility is a one story structure on the grounds of a church. Facility grounds consists of (1) administrative office, (1) kitchen area, (1) activity room, (2) bathrooms, (1) activity room(1), classroom, and (1) storage room. Common areas such as bathroom and the main activity rooms were observed. There is also an outdoor patio area for clients to utilize. The first aid kit is fully stocked with a Red-Cross Manual. There are no medications being kept at this facility.

LPA Shirley reviewed all client files and 4 staff files and all had required documents.

LPA Shirley and Ericka toured the physical plant. There were no bodies of water or obstructions on the premises. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water delivered at 114.6 F.

Four (4) fire extinguishers were observed to be fully charged.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a hard copy of this report was provided to Ericka Yamashiro.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2024
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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