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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202826
Report Date: 05/15/2022
Date Signed: 05/16/2022 08:08:32 AM

Document Has Been Signed on 05/16/2022 08:08 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WITHERS ADULT RESIDENTIAL FACILITY #1FACILITY NUMBER:
198202826
ADMINISTRATOR:PEGGIE M. WITHERSFACILITY TYPE:
735
ADDRESS:841 EAST MEADBROOK STREETTELEPHONE:
(310) 323-6895
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 6DATE:
05/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Patricia WinbushTIME COMPLETED:
11:00 AM
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On 05/15/22, at 8:57 am, Licensing Program Analyst (LPA)/ Susan Campos conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Assistant Administrator, Patricia Winbush, and explained the purpose of today’s visit. This facility is a level 3 home, licensed to serve 6 Ambulatory Developmentally Disabled adults ages 18 to 59 years old. Vendorized with the South Central Los Angeles Regional Center. The last fire drill was conducted February 20, 2022. There are currently (6) South Central Regional Center clients in placement. All (6) clients are ambulatory. LPA Campos and Ms. Winbush toured the entire facility inside and outside grounds. The facility is a two-story structure located in a residential neighborhood. The home consists of the following: 5 bedroom (4 client bedrooms and 1 staff bedroom), 2 bathrooms, family room, dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry room and an attached garage.

The LPA and Ms. Winbush toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The facility hot water temperature measured 105.6 degrees Fahrenheit. A comfortable temperature of 75 degrees Fahrenheit was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. The facility fire extinguisher is charged. Smoke detectors and carbon monoxide are operable. A review of Medication Administration Records (MAR) was observed to be maintained in order and accurate.

Evaluation Report Continued on LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WITHERS ADULT RESIDENTIAL FACILITY #1
FACILITY NUMBER: 198202826
VISIT DATE: 05/15/2022
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. The LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Ms. Winbush.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2022
LIC809 (FAS) - (06/04)
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