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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601613
Report Date: 08/21/2024
Date Signed: 08/21/2024 02:31:05 PM

Document Has Been Signed on 08/21/2024 02:31 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: DATE:
08/21/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Jun FloresTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 08/21/2024 at 2:00pm, an office meeting was held by the El Segundo Adult & Senior Care Regional Office. Present during the meeting was Licensing Program Manager (LPM) Janae Hammond , Licensing Program Analyst (LPA) Lizeth Villegas and facility Administrator Jun Flores. The purpose of todays meeting was to discuss the facility administrative oversight noncompliance concerns.

During today’s meeting LPM Hammond discussed the annual inspection conducted on 08/10/2024 by LPA Ernand Dabuet. During the annual inspection the facility was issued citations for Maintenance & Operation, Buildings & Grounds, Health Related Services, Personnel Records and Client Medical Assessments. During the annual inspection LPA observed and infestation of bedbugs.

As a result of the annual inspection LPM Hammond discussed the following items the Licensee will need to complete.

Licensee to update the following documents and submit to CCL by the following dates:
· Personnel report LIC 500 by 08/30/24
· Designation of Administrative Responsibility LIC 308 by 08/30/24
· Reach to pest control company to inquire about the best treatment plan to eradicate the bed bugs. Licensee to ensure facility is treated for bed bugs multiple times monthly . Licensee to provided copy of service agreement to CCL by POC due date 09/03/24.
· Bed Bug monitoring plan/ Maintain a weekly log and submit to CCL every Friday by 5:00 PM. The log shall include all rooms and document the date they were checked for bed bug and document if any bed bugs were found by facility staff.
· Licensee shall ensure there is a backup Administrator when the Administrator is unavailable.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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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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: 08/21/2024
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LPM stated CCL will be doing the following:

· Frequent case management visits.
· Yearly Comprehensive Annual Inspections.

RO asked the Licensee if they would like to participate in the Technical Support Program (TSP) and the Licensee accepted.

Exit Interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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