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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601613
Report Date: 08/10/2024
Date Signed: 08/10/2024 01:30:58 PM

Document Has Been Signed on 08/10/2024 01:30 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:WILMINGTON GARDENSFACILITY NUMBER:
191601613
ADMINISTRATOR/
DIRECTOR:		FLORES,V.ANDT.FACILITY TYPE:
735
ADDRESS:1311 WEST ANAHEIM STREETTELEPHONE:
(310) 835-6366
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY: 48CENSUS: 43DATE:
08/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Fay Pacificador TIME VISIT/
INSPECTION COMPLETED:
01:59 PM
NARRATIVE
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On 08/10/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with House Manager Fay Pacificado and explained the purpose of today’s visit. Administrator Jun Flores is not available to participate for this inspection visit. The facility is licensed to operate for forty-eight (48) ambulatory mentally disabled adults ages 18-59.

There are currently (43) forty-three clients in placement. All forty-three (43) 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 commercial 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 House Manager 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 suitable 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 105.0 F-111.5 F in the bedrooms. A comfortable temperature is maintained in the facility between 76 -79 degrees F. 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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2024
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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Document Has Been Signed on 08/10/2024 01:30 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/10/2024 at 12:15 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed toxic cleaning solutions stored along with food supply in the pantry. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2024
Plan of Correction
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Licensee will remove all toxic chemicals from the food pantry and stored in safe cabinet not accessible to clients. Proof of correction must be sent to sent via email to ernand.dabuet@dss.ca.gov by due date.
*corrected during visit*
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed medications in bathroom shared by clients in room #29-#30 in top drawer.. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2024
Plan of Correction
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Licensee will remove medications from bathroom drawer and store in a cabinet not accessible to clients. Proof of correction must be sent to sent via email to ernand.dabuet@dss.ca.gov by due date.
*corrected during visit*
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2024 01:31 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/10/2024 at 12:17 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) 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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed live bed bugs on client's bed for room #27. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee will perform pest control spray in room #27 and replace with new beds and sheets. Proof of correction must be sent to sent via email to ernand.dabuet@dss.ca.gov by due date.
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The facility is unable to provide proof of a current Administrator Certificate on file for Jun Flores. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee will send a copy of a current Administrators Certificate for Jun Flores. Proof of correction must be sent to sent via email to ernand.dabuet@dss.ca.gov by due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2024


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Document Has Been Signed on 08/10/2024 01:31 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/10/2024 at 12:18 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee did not comply with the section cited above. LPA identified staff #1-#6 all did not have current/active First Aid/CPR Training Certificates completed. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee will ensure that all staff have completed First Aid/CPR training and it is current and active. Proof of correction must be sent to sent via email to ernand.dabuet@dss.ca.gov by due date.
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee did not comply with the section cited above. LPA identified client #5 did not have current/active Needs/Service Plan on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee will ensure that all clients including client #5 have a completed Needs/Services Plan and it is current and active. Proof of correction must be sent to sent via email to ernand.dabuet@dss.ca.gov by due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2024


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Document Has Been Signed on 08/10/2024 01:31 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/10/2024 at 12:19 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified clients #2, #3, and #5 did not have a physcians report LIC 602 on file. This violationi which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee will ensure all clients have a physicians report LIC 602 on file. Proof of correction must be sent to sent via email to ernand.dabuet@dss.ca.gov by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613
VISIT DATE: 08/10/2024
NARRATIVE
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An audit of clients #1-#5 (C1-C5) service files and staff #1-#6 (S1-S6) personnel files were performed. The facility has a $1135.00 annual fees due by 10/14/24. The facility has a current liability insurance effective 05/17/24 - 05/17/25.

DEFICIENCIES:
  • LPA observed toxic cleaning solutions stored in food pantry along with food supply.
  • LPA observed medications stored in bathroom drawer accessible to clients in Room #29-#30.
  • LPA observed active bed bugs in Room #27.
  • LPA observed in bathroom #27 toxic bathroom cleaning solution accessible to clients.
  • Facility did not have a current Administrator Certificate on file.
  • Staff #1-#6 did not have current/active First Aid/CPR completed training certificate.
  • Client #5 did not have Need/Service Plan on file.
  • Client #2, #3 and #5 did not have a Physicians Report LIC 602 on file.


Advisory Notes – Two (2) Technical Assistance/Violation were issued, please see LIC9102-AN.

According to the California Code of Regulations (Title 22, Division 6, Chapter 6), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).


An exit interview conducted with Fay Pacificador and a copy of the report was provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2024
LIC809 (FAS) - (06/04)
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