198200355-6-3-2024-11-AS-FSHY-D5VQJD-20240603121234

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200355
Report Date: 06/03/2024
Date Signed: 06/03/2024 12:12:58 PM

Document Has Been Signed on 06/03/2024 12:12 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:	SCR ADULT RESIDENTIAL CARE		FACILITY NUMBER:	198200355
ADMINISTRATOR/ DIRECTOR:	CHARLES E. MILES		FACILITY TYPE:	735
ADDRESS:	1707 W 153 ST		TELEPHONE:	(310) 538-2433
CITY:	GARDENA	STATE: CA	ZIP CODE:	90249
CAPACITY: 4		CENSUS: 3	DATE:	06/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:01 AM
MET WITH:	Charles C. Singson , Licensee		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 06/3/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Charles Singson and explained the purpose of today’s visit and was granted entry. The facility is licensed to serve elderly developmentally disabled residents ages 18 – 59.

LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, training, and certification. LPA reviewed the surety bond. LPA received a copy of the Liability Insurance.

LPA Felisa, Jarice and Charles toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (2) client bedrooms, workout room, (1 1/2) bathroom, den(office), living room, kitchen, dining area, garage used for storage and laundry area. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1 and 2 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley, Jarice and Charles toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 118.3 degrees Fahrenheit.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

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: SCR ADULT RESIDENTIAL CARE	FACILITY NUMBER: 198200355
	VISIT DATE: 06/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The (1 1/2) bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley, Jarice and Charles walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen and laundry area. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

There were no deficiencies observed.

An exit interview was conducted, and a copy of this report was provided to Administrator Assistant, Jarice Ware.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2