198320093-6-3-2024-11-AS-FSHY-D5VVER-20240603162245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320093
Report Date: 06/03/2024
Date Signed: 06/03/2024 04:22:51 PM

Document Has Been Signed on 06/03/2024 04:22 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:	GARDENIA HOME		FACILITY NUMBER:	198320093
ADMINISTRATOR/ DIRECTOR:	MARTIN, LATIESHA		FACILITY TYPE:	735
ADDRESS:	510 WEST 169TH STREET		TELEPHONE:	(832) 991-1938
CITY:	GARDENA	STATE: CA	ZIP CODE:	90248
CAPACITY: 4		CENSUS: 4	DATE:	06/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:04 PM
MET WITH:	Lavida Childs, Home Manager		TIME VISIT/ INSPECTION COMPLETED:	04:22 PM

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On 6/3/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Home Manager, Lavida Childs and explained the purpose of today’s visit. The Administrator, La Tiesha Martin arrived shortly after. The facility is licensed to serve elderly developmentally disabled residents ages 18-59.

LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (6) staff files and found they contained the required documents, training, and certification.

LPA Felisa and La Tiesha toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (2) bathroom, living room, kitchen, dining area, patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and La Tiesha toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored in cabinets above the pantry in the kitchen. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 107.2 degrees Fahrenheit.

con'd 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

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

FACILITY NAME: GARDENIA HOME	FACILITY NUMBER: 198320093
	VISIT DATE: 06/03/2024

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The (2) bathrooms have grab bars and are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and La Tiesha walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen and in the garage. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

LPA did not observe any deficiencies during this visit.

An exit interview was conducted, and a copy of this report was provided to Administrator, La Tiesha Martin.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC809 (FAS) - (06/04)

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