198320068-7-18-2026-11-AS-MCOA-DW4UTS-20260718155226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320068
Report Date: 07/18/2026
Date Signed: 07/18/2026 03:52:39 PM

Document Has Been Signed on 07/18/2026 03:52 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	CN HOME #6		FACILITY NUMBER:	198320068
ADMINISTRATOR/ DIRECTOR:	MAE MAUREEN A TORRES		FACILITY TYPE:	735
ADDRESS:	1724 W 240TH STREET		TELEPHONE:	(310) 326-6219
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY: 6		CENSUS: 4	DATE:	07/18/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:16 PM
MET WITH:	Mae Maureen Torres, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Mae Maureen Torres, Administrator, and the reason for the visit was explained.

The facility is licensed to serve (6) non-ambulatory, developmentally disabled adults ages 18 through 59. Currently, there are (4) clients living in the home. Clients are provided services through the Harbor Regional Center. Three (3) of the clients have Restricted Health Conditions and (4) are utilizing postural supports or protective devices.

The single-story home is in in a residential area of Lomita an consists of the following (4) client bedrooms, (2) bathrooms, staff office, living room, kitchen, dining room, recreational room, relaxation room, laundry room, a de-attached garage, and an outdoor shaded area.

The following was observed during today’s visit:

Facility is clean and walkways and exits are free of debris and obstructions. Furniture throughout the facility is in good repair; however, carpet in the recreational room was observed unclean. The carpet has stains by the overflow refrigerator and by the door leading to the side driveway. Also observed, two tears on the carpet by the same door. Bedrooms have the required furniture such as specialized beds, dressers, lamps, and chairs. Clients’ beds are clean and postural positioning mechanisms are working properly. Mattresses and bedding are kept clean and dry. Laundry room is also clean and washer and dryer were observed to be operational.

***Continues on LIC 809-C***

Wei Siew Ho
Mayra Cota
	DATE: 07/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2026

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CN HOME #6	FACILITY NUMBER: 198320068
	VISIT DATE: 07/18/2026

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Kitchen appliances are clean and were observed to be working properly. Bathrooms were inspected and observed clean and sanitary. Facility has sufficient client nourishment and is kept properly stored. Bathrooms are equipped with anti-slip surfaces and and grab bars. Bathrooms were observed clean and sanitary. Water temperature was tested and measured within the required 105 - 120 degrees F. Sufficient incontinent care and personal hygiene supplies were observed.

The outdoor areas are clean and there are no pools or large bodies of water. Patio furniture was observed clean and in good repair. Outdoor passageways and ramps are kept free of debris and obstructions.

Smoke and carbon monoxide detectors were tested and are working properly. Fire extinguisher in the home is kept charged and was last inspected on 3/16/2026. Fire/safety drills are conducted monthly. Last fire/safety drill was conducted on 6/22/2026. First Aid kit was inspected and contains the required tools and manual

Four (4) client and (3) staff files were reviewed and contained required documentation. Medication is kept centrally stored, locked and inaccessible to residents. Medication was observed to be administered and documented accordingly.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiency is noted and citation issued during today's visit. Exit interview conducted with Mae Torres, Administrator and a copy of the report, 809-D and Appeal Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2026 03:52 PM - It Cannot Be Edited

Created By: Mayra Cota On 07/18/2026 at 02:00 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: CN HOME #6	FACILITY NUMBER: 198320068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to carpet in the recreational room was observed unclean. The carpet has stains by the overflow refrigerator and by the door leading to the side driveway. Also observed, two tears on the carpet by the same door which poses/posed a potential health, safety or personal rights risk to staff and persons in care.
	POC Due Date: 08/21/2026
	Plan of Correction
1 2 3 4	Licensee will replace the carpet in the recreation room by POC due date.

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.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2026

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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