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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608587
Report Date: 09/08/2021
Date Signed: 09/08/2021 06:13:39 PM

Document Has Been Signed on 09/08/2021 06:13 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:SPECIALIZED RESIDENTIAL HARGISFACILITY NUMBER:
197608587
ADMINISTRATOR:CRYSTAL GARCIAFACILITY TYPE:
735
ADDRESS:8924 HARGIS STTELEPHONE:
(310) 287-1491
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY: 3CENSUS: 3DATE:
09/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Crystal GarciaTIME COMPLETED:
02:10 PM
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 Licensing Program Analyst (LPA) Jey Cardenas conducted a case management - incident visit to check on the health and safety of clients in care on 09/08/2021 at approximately 12:12pm. LPA met with Administrator, Crystal Garcia, LPA conducted risk assessment, the facility is clear of Covid-19 infection. LPA informed Ms. Garcia that the purpose of today's visit was to follow-up on an Unusual Incident and Injury Report received by the Department relating to unexplained injuries on Client (C1).

During today's visit, LPA toured the facility with Miss Garcia. LPA observed the clients to identify any immediate health and safety threats. LPA attempted to interview C1, however LPA was unable to communicate with client due to client is non-verbal. C1 body check was conducted by Ms. Garcia and LPA observed bruising on C1s body. LPA reviewed C1's file and staff files.

LPA requested the following documents:

- Staff and client roaster


-Pictures of C1s bruises.
-Staff statements related to the incident.
-C1's IPP/ Needs and services/ Appraisal/ Emergency sheet/ Physicians Report
-Staff file records

No deficiencies were cited. Exit interview conducted and a copy of this report to be provided to Administrator, Crystal Garcia via email.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
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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