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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601613
Report Date: 11/16/2022
Date Signed: 11/16/2022 02:53:07 PM

Document Has Been Signed on 11/16/2022 02:53 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: 45DATE:
11/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Administrator - Vic Jun FloresTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Don Senaha conducted a case management visit to the above facility. LPA Senaha received an incident report and death report regarding client (C1). LPA gathered pertinent documents.

The following was discussed with facility representative: Reporting Requirements. Per California Code of Regulations, Title 22 the following deficiency was observed and cited: (Refer to LIC 809-D).

Exit interview conducted, with Administrator Vic Jun Flores, appeal rights issued, and a copy of the report was provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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Document Has Been Signed on 11/16/2022 02:53 PM - It Cannot Be Edited


Created By: Don Senaha On 11/16/2022 at 12:55 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: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited
CCR
80061(b)(1)(A)

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80061(b)(1)(E)Reporting Requirements. Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to licensing agency within the agency's next working day...(E)Any unusual incident or client absence which threatens the physical or emotional...
This requirement is evidence by:
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Administrator completed an incident report for this incident on site. Administrator has read Title 22, Division 6 Chapter 1 reporting requirements.
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Based on record reviews and interview, the Administrator, did not report the the incident of a client which poses a potential health and safety risk to persons in care.
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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