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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202826
Report Date: 05/12/2023
Date Signed: 05/12/2023 01:34:46 PM

Document Has Been Signed on 05/12/2023 01:34 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, 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:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Patricia WinbushTIME COMPLETED:
02:00 PM
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On 05/12/2023, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new Care Inspection Tool. LPA was met by Patricia Winbush, Caregiver, and the purpose of today’s visit was explained. The facility is licensed to operate for (6) ambulatory (developmentally disabled or Mentally Ill) adults ages 18 through 59. Currently, the home has (6) clients. The clients are South Central Los Angeles Regional Center clients. None of the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facilities annual fees are current.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: 4 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.



LPA and Ms. Winbush toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Floors and window screens were in good repair. 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 water temperature was within title 22 guidelines (105-120f). A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients.

Report continued on LIC809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WITHERS ADULT RESIDENTIAL FACILITY #1
FACILITY NUMBER: 198202826
VISIT DATE: 05/12/2023
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The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. LPA observed that the last fire/emergency drill was conducted on 04/07/2023.

LPA conducted a records review of (6) client records, (5) staff records, (6) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (6) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. Sanitizing stations ( Located in common areas and restrooms) were stocked with masks, gloves, and sanitizers. LPA observed staff were wearing face coverings and LPAs temperature was taken upon entry. LPA observed the facility to have a 60-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov ) for Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance and other advisories.



During today’s visit there were no deficiencies observed.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Patricia Winbush, Caregiver.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
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