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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609564
Report Date: 01/09/2025
Date Signed: 01/09/2025 01:04:32 PM

Document Has Been Signed on 01/09/2025 01:04 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:WHOLE CARE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197609564
ADMINISTRATOR/
DIRECTOR:		JONHSON, KURTFACILITY TYPE:
735
ADDRESS:1661 W. 106TH STTELEPHONE:
(310) 953-7486
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 3DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Johnson KurtTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 01/09/2025, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced required 1- year visit using the new CARE Inspection Tool. Upon arrival at the facility, LPA Richard met with Licensee Kurt Johnson and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently three (3), Westside Regional Center (WRC) Adult Residential Care Facility (ARF) consumers in placement.

The facility is a single-family home located in a residential neighborhood. Licensee Mr. Johnson and LPA Richard toured the facility which consisted of the following: Living room, kitchen, dining area, 4 bedrooms, bathroom, laundry area, locked medication cabinet in the living room, shaded area, and indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit.
Documents are posted as mandated. Bedrooms contain the furniture mandated, and bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food.

See continued LIC809-C on page 2
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 2
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: WHOLE CARE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197609564
VISIT DATE: 01/09/2025
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Continued LIC809-C page 2

The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas were observed for the ability to safely serve the needs of the residents, including cleanliness, and clearness of any potential hazards to the residents. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas were observed for the ability to safely serve the needs of the residents, including cleanliness, and clearness of any potential hazards to the residents.

The first aid kit with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 110.3F degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working, resident. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. The licensee stated staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited. Exit interview conducted. A copy of this report was provided to the Licensee.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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