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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320144
Report Date: 02/08/2024
Date Signed: 02/09/2024 08:39:37 AM

Document Has Been Signed on 02/09/2024 08:39 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:SMITH FAMILY RESIDENTIAL CAREFACILITY NUMBER:
198320144
ADMINISTRATOR:BROWN, KENYAFACILITY TYPE:
735
ADDRESS:10518 S. 7TH AVENUETELEPHONE:
(323) 777-6161
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6; 6CENSUS: 4DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Kenya BrownTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Licensee Kenya Brown and explained the purpose of today's Annual Inspection. LPA Bunker verified that the facility has an approved mitigation plan report. and an infection control report. LPA Bunker verified all current staff fingerprints cleared/associated with the facility. There are currently four (4), Westside Regional Center consumers in placement. The facility's annual fees are current.

The facility is a single-story family home located in a residential neighborhood. Licensee Ms. Brown, LPAs Bunker toured the facility which consisted of the following: Living room, 5 bedrooms, and 3 1/2 bathrooms. There is a check-in station, living room, full kitchen/dining area, family room, kitchenette/dining area, sitting area, laundry room, locked supply closet, laundry room, patio area, shaded area, and indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit. Bedrooms #1-5 are designated as clients' bedrooms.

Due to time constraints, LPA Bunker will return at a later date to conclude the visit.
There were no deficiencies cited.
Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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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