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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601377
Report Date: 02/15/2024
Date Signed: 02/16/2024 09:38:58 AM

Document Has Been Signed on 02/16/2024 09:38 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EXCELSIOR HOUSEFACILITY NUMBER:
191601377
ADMINISTRATOR:JAVANFARD, ELANFACILITY TYPE:
772
ADDRESS:1007 SOUTH MYRTLE AVENUETELEPHONE:
(310) 412-4191
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY: 14CENSUS: 10DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Vanessa Felix OjedaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1-year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA were properly screened for COVID-19 symptoms and their temperature was checked. LPA Bunker met with Intake Discharge Coordinator (IDC) Vanessa Felix Ojeda. LPA Bunker explained the purpose of today's Annual Inspection. LPA Bunker verified that the facility has an approved mitigation plan report and infection control report. The facility's annual fees are current. The facility currently has ten (10) ambulatory clients in placement.

The facility is a two-story building located in a business/residential neighborhood. IDC staff Vanessa and LPA Bunker made a complete tour of the facility which consisted of upstairs and downstairs.

The downstairs consists of the main office, living room/common area, dining room/group meeting area, kitchen, Administrator's office, Counselor's office, Therapist's office, medication room, arts, and craft closet, two (2) all-gender bathrooms, utility closet emergency supplies room, and numerous of storage closets are downstairs. The upstairs has seven (7) bedrooms, two (2) all-gender bathrooms, one (1) all-gender staff restroom, laundry room, staff lounge, Doctor's office, Director's office, and numerous storage closets. The outside includes a gated front parking lot, a backyard-covered patio/shaded areas, and indoor/outdoor activity areas.

Due to time constraints and insufficient information available at this time, the above allegations need further investigation. No deficiencies were cited. An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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