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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601613
Report Date: 11/16/2022
Date Signed: 11/16/2022 02:55:13 PM

Document Has Been Signed on 11/16/2022 02:55 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Vic Jun FloresTIME COMPLETED:
03:00 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
On 11/16/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Vic Jun Flores and explained the purpose of today’s visit. The facility is licensed to operate for forty-eight (48) ambulatory mentally disabled adults ages 18-59.


There are currently (45) forty-five clients in placement. All forty-five (45) clients are ambulatory. The facility is two buildings next to each other with one side being two stories and the other side being a one story horseshoe of rooms. The facility is located in a residential neighborhood. It consists of the following: 25 client bedrooms, 12 full bathrooms, three (3) storage rooms, activity room, office, lobby, side patio, shaded area front patio, kitchen, dining room, outdoor activity area, laundry room and a parking lot.

LPA and Administrator toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms are occupied by clients and contain the mandated furniture. The bathrooms are clean and operational. Fire alarm system, and carbon monoxide detector are in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. The water temperature measured 114.0 F-119.5 F in the bedrooms and kitchen sink. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food is available. Linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, fire extinguishers are fully charged. First Aid kit complete and with manual in the office. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards.



Evaluation Report Continues on LIC 809-C
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)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613
VISIT DATE: 11/16/2022
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
26
27
28
29
30
31
32
During the visit, LPA observed the facility infection control practices. Please see LIC 9102-AN for all Technical Assistance issued.

Advisory Notes – Three (3) Technical Assistance were issued, please see LIC9102-AN.

There was also a case management completed during the inspection visit. There were no deficiencies cited for the annual visit.

An exit interview was conducted and a copy of this report was provided to Administrator Vic Jun Flores.
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
LIC809 (FAS) - (06/04)
Page: 2 of 5