<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320034
Report Date: 08/04/2023
Date Signed: 08/04/2023 04:57:34 PM

Document Has Been Signed on 08/04/2023 04:57 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CN HOME #5FACILITY NUMBER:
198320034
ADMINISTRATOR:MATHARU, PRITAMFACILITY TYPE:
735
ADDRESS:2207 ARLINGTON AVETELEPHONE:
(310) 612-0978
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 3DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Mae Maureen TorresTIME COMPLETED:
05:00 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 08/04/2023, Licensing Program Manager (LPM) Ulysses Cornel and Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual required visit using the new CARE Inspection Tool. LPM and LPA met with administrator, Mae Maureen Torres and explained the purpose of today’s visit. The facility is licensed to operate for four (4) adult clients of between the ages of 18 through 59. 2 of 3 clients are Harbor Regional Center clients. 3 of 3 clients have Restricted Health Care Conditions. 3 of 3 clients are over 59 years of age.

Due to time constraints a Case Management - Annual Continuation visit will be conducted.

Deficiencies were observed during todays visit, plans of corrections were developed with the administrator.

A copy of this report, appeals rights and civil penalty assessment was provided to Mae Maureen Torres, administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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 4
Document Has Been Signed on 08/04/2023 04:57 PM - It Cannot Be Edited


Created By: Regina Cloyd On 08/04/2023 at 04:22 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CN HOME #5
FACILITY NUMBER: 198320034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 4 staff present during today's visit did not have their crimninal record clearances wre not asscocated to this faciliy, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2023
Plan of Correction
1
2
3
4
The administrator will provide a plan to ensure future compliance to Ttitle 22 Regulation 80019(e)(3), proof of correction will be submitted to CCL at regina.cloyd@dss.ca.gov by POC due date.
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 4 staff present during today's visit did not have their crimninal record clearances not asscocated to this faciliy, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
1
2
3
4
No plan of correction needed. The administrator processed the transfer of criminal record clearances of 3 out of 4 staff observed during todays visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4