<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601613
Report Date: 08/05/2022
Date Signed: 08/05/2022 03:38:01 PM

Document Has Been Signed on 08/05/2022 03:38 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:WILMINGTON GARDENSFACILITY NUMBER:
191601613
ADMINISTRATOR:FLORES,V.ANDT.FACILITY TYPE:
735
ADDRESS:1311 WEST ANAHEIM STREETTELEPHONE:
(310) 835-6366
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY: 48CENSUS: 47DATE:
08/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Fey Pacific AdorTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jey Cardenas conducted a case management visit to the above facility; during an initial 10 day complaint investigation visit made (control number 11-AS-20220727130322) LPA observed deficiencies not-related to the complaint investigation. The following was discussed with facility representative: Reporting Requirements, and Building and Grounds.

On todays visit LPA conducted a covid-19 risk assessment, LPA was notified that facility has two active covid-19 cases. Per LPA review on FAS, facility has not reported the current covid cases (two/ staff) to community care licensing. LPA spoke with Administrator, Flores who confirmed that the current cases have not been reported and he was unaware that this was a requirement.

During tour of the facility, LPA observed room#5 to be full of clutter, items such as tin cans and junk is were spread out through the floor, stacked up, bed is not leveled; bedroom is not safe and sanitary.

Per California Code of Regulations, Title 22 the following deficiencies were observed and cited: (Refer to LIC 809-D)

Exit interview conducted, appeal rights issued, and a copy of the report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/05/2022 03:38 PM - It Cannot Be Edited


Created By: Jey Cardenas On 08/05/2022 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2022
Section Cited
CCR
80061(a)

1
2
3
4
5
6
7
Reporting Requirements Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. This requirement not met as evidenced by: On 8/5/22 Administrator, Flores confirmed
1
2
3
4
5
6
7
Administrator will submit incident report with covid-19 cases via fax to CCLD.
client/ staff name, test date, results date, vaccination status and vaccination/booster dates.
8
9
10
11
12
13
14
facility has not reported current covid-19 positive cases. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
08/19/2022
Section Cited
CCR80087(2)

1
2
3
4
5
6
7
Buildings and Grounds- The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement not met as evidenced by: On 8/5/22 LPA Cardenas observed bedroom#5
1
2
3
4
5
6
7
Administrator will meet with client to ensure the bedroom is cleared and organzied to ensure a safe environment. Send pictures to LPA via fax by POC date.
8
9
10
11
12
13
14
full of clutter throghout the floors and unleveled bed. This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Jey Cardenas
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2