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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320034
Report Date: 08/01/2024
Date Signed: 08/01/2024 11:22:17 AM

Document Has Been Signed on 08/01/2024 11:22 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CN HOME #5FACILITY NUMBER:
198320034
ADMINISTRATOR/
DIRECTOR:		MATHARU, PRITAMFACILITY TYPE:
735
ADDRESS:2207 ARLINGTON AVETELEPHONE:
(310) 612-0978
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 3DATE:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:13 AM
MET WITH:Administrator Mae TorresTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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On 08/01/2024, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator Mae Maureen Torres. LPA explained the purpose of the visit and were accompanied by Staff inside the facility during this inspection. The facility is licensed to operate for four (4) adult clients of between the ages of 18 through 59. The clients are Harbor Regional Center clients. One client has a Restricted Health Care Conditions.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, two (2) office spaces with one in the kitchen area and the other in a separate closed-door area, three (3) bathrooms, one (1) dining area, office, activity room and kitchen. There is an outside shaded area in the front yard with ample seating. The laundry area is located near between rooms #2 and #3. There is also a detached storage area behind the house.

Outside grounds were toured and no bodies of water were observed. There are no security bars or weapons on the premises.

Four (4) out of four (4) client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CN HOME #5
FACILITY NUMBER: 198320034
VISIT DATE: 08/01/2024
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Two (2) bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Cloyd tested hot water temperature and it measured at 111.2 degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.



LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 07/10/24. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

Five (5) staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

Three (3) client records were reviewed and, 3 out of 3 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. Two client medications were reviewed. LPA Cloyd reviewed 2 out of 2 client P&I.

No deficiencies cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with the Administrator Mae Torres.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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