198200355-5-13-2025-11-AS-FSHY-DGM295-20250512171121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200355
Report Date: 05/12/2025
Date Signed: 05/13/2025 08:21:48 AM

Document Has Been Signed on 05/13/2025 08:21 AM - 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:	05/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:38 PM
MET WITH:	Charles Singson, Licensee		TIME VISIT/ INSPECTION COMPLETED:	05:15 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 5/12/25, Licensing Program Analyst (LPA) Felisa Shirley arrived unannounced to conduct an Annual Required - 1 Year Inspection and met with Licensee, Charles Singson. LPA disclosed the purpose of the inspection was granted entry into facility by the Licensee. The current census is 3. Walk through inspection was conducted by LPA Shirley and Charles inside and outside to ensure that there are no health and safety hazards. DINING ROOM: LPA Felisa and Charles inspected the dining room and found it to be clean and all the furniture was in good working order. There were adequate number of chairs and a place at the table for all residents in the facility. KITCHEN: LPA Shirley observed the kitchen to be clean and sanitary and all appliances were operable. Knives were properly secured in a drawer below the stove. The facility has a sufficient supply of perishable and non-perishable foods. The pantry was well stocked. LPA Shirley noted that the water temperature delivered at 116.5 F. LIVINGROOM: LPA Shirley and Charles inspected the Livingroom. LPA observed it to be clean and free of dirt with a comfortable room temperature. There were working lights, and no fireplace or open face heating. BEDROOMS: LPA Shirley and Charles inspected the bedrooms. There are 3 bedrooms, 2 occupied by clients with beds, accommodating chairs for every resident. Con'd on 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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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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: 05/12/2025

NARRATIVE

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BATHROOM: LPA Shirley and Charles toured both bathrooms. LPA found the bathrooms to be clean, paper towels and soap.

BACKYARD: LPA Shirley and inspected the backyard and found it to be clean and a shaded area for the residents. LPA observed that there was no pool or bodies of water.

LPA Shirley found there to be several hardwired smoke/carbon monoxide detectors in the facility. 1 in the hallway, 1 in the kitchen and Livingroom, 1 in every bedroom. LPA found that the hallway was clear of any obstructions. Fully stocked linen closets in the hallway.

LPA Shirley found there to be 1 fully charged fire extinguisher located in the kitchen and one located in the laundry room. It was maintained and serviced yearly. Inspection record was up to date and tags visible.

LPA Shirley reviewed all client files and found that they contained all required documents. LPA reviewed 5 Staff Personal files, and LIC 500 and found that all staff are associated with our records in Guardian.

LPA Shirley reviewed 3 staff files and found that they did not have their TB test results.

Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D.

An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were and left with the Licensee, Charles Singson whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/13/2025 08:21 AM - It Cannot Be Edited

Created By: Felisa Shirley On 05/12/2025 at 04:41 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: SCR ADULT RESIDENTIAL CARE	FACILITY NUMBER: 198200355
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which 3 staff, Jarice Ware, Michelle Griffith and Tawny Logan do not have TB results in their personnel files which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/26/2025
	Plan of Correction
1 2 3 4	Administrators shall get staff tested and provide copies of TB test results and submit to CCLD by POC due date of 5/26/25, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:

	Felisa Shirley
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC809 (FAS) - (06/04)

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