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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601613
Report Date: 10/08/2025
Date Signed: 10/08/2025 12:21:39 PM

Document Has Been Signed on 10/08/2025 12:21 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: 42DATE:
10/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Administrator Jun V FloresTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 10/08/25, Licensing Program Analyst's (LPA) Villegas and Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Administrator Vic Jun Flores as the purpose of the visit was explained. he facility is licensed to operate for (48) ambulatory mentally disabled adults ages 18-59. Annual fees are current.

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, 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. No firearms are stored at facility and no bodies of water present.

LPA Iniguez 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 suitable and operational. Fire alarm system, and carbon monoxide detector are in compliance and operational. Medications are stored, locked and inaccessible to clients. The water temperature measured 105.0 F-120 F in the bedrooms. Ample supply of perishable and nonperishable food is available. Linens and personal hygiene supplies are adequate, 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.


LPA Villegas conducted a review of 4 client records, 4 staff records, and 4 medication administration records.
Exit interview conducted, appeal rights explained, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/08/2025 12:21 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 10/08/2025 at 11:20 AM
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: 10/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)

85064 Adminstrator Qualifications and Duties
All adult residential facilities shall have a certified administrator.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as there is no proof of active administrator certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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Administrator to provide proof of an active Administrator certificate to LPA by POC due date.
Type B
Section Cited
CCR
80066(e)
80066 Personnel Records

All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.


Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Administrators file was not available for review at the time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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Administrator to ensure Administrator file is located at the facility at all times, Administrator to send copies of all required documents to LPA to review by POC 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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 12:21 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 10/08/2025 at 11:37 AM
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: 10/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10-11)
80066 Personnel Records
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

A health screening as specified in Section 80065(g).
Tuberculosis test documents as specified in Section 80065(g).

Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as staff #2-4 do not have a completed health screening on file, additionally LPA did not observe a TB test for staff #3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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Administrator to provide copies of completed and signed by physican health screening and TB test for staff #2-4 by POC due date.
Type B
Section Cited
CCR
80075(f)
80075 Health Related Services
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.
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above as LPA observed CPR cetification to be expired for Staff #2-4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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Administrator to have all staff responsible for providing direct care and supervision to be trained in CPR and send proof of training completion by POC 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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 12:21 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 10/08/2025 at 11:46 AM
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: 10/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(7)(15)(17)
80076 Food Services
In facilities providing meals to clients, the following shall apply: Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained. Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored. All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above as toxins were observed to be stored in food preparation area and food storage area, rotten carrots were store in the refrigarator, the refrigarator and freezer has dried blood from stored proteinwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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Administrator to ensure toxin are stored away from food preparation areas and food storage areas, Administrator to produce a plan on how the facility kitchen will get into compliance with sanitation regulations, and how staff will ensure all expired/rotten food is not left in refrigarator with other produce. Plan to be sent to LPA by POC 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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 12:21 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 10/08/2025 at 12:03 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: 10/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
80087 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.


Deficient Practice Statement
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Based on [(observation) , the licensee did not comply with the section cited above as LPA observed live bed bugs on client's bed for room #s 1, 23, 24, and 26 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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Licensee will perform pest control spray in room #s 1. 23.24.and 26 and replace with new beds and sheets. Proof of correction must be sent to LPA by POC due date.
Type B
Section Cited
CCR
80069(b-c)(1)
80069 Client Medical Assessment
In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.
The medical assessment shall include the following: The results of an examination for communicable tuberculosis and other contagious/infectious diseases.
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above as client # 3 did not have a medical assessment nor TB test on record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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Administrator to have client #3 obtain a medical assessment and TB test by POC due date. Proof to be sent to LPA by POC 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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2025


LIC809 (FAS) - (06/04)
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