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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320144
Report Date: 02/19/2025
Date Signed: 02/19/2025 02:58:55 PM

Document Has Been Signed on 02/19/2025 02:58 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:SMITH FAMILY RESIDENTIAL CAREFACILITY NUMBER:
198320144
ADMINISTRATOR/
DIRECTOR:		BROWN, KENYAFACILITY TYPE:
735
ADDRESS:10518 S. 7TH AVENUETELEPHONE:
(323) 777-6161
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6; 6CENSUS: 4DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Kenya Brown, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 02/19/2025 at 11:15am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Kenya Brown, Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for 6 ambulatory, ages 18 through 59. Currently, the home has 4 clients. The clients are Westside Regional Center clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facility annual fees are paid in full. The liability insurance is with AmGuard Insurance Company (policy period 08/08/2024 - 08/08/2025) with each occurrence limit at $1,000,00 and general aggregate limit at $3,000,000. The last emergency drill was conducted on 02/02/2025.

The facility is located in a residential neighborhood. The property consists of the following: 4 client bedrooms, 1 in staff bedroom, 2 bathrooms (1 common, 1 private for one of the clients), 1 half bedroom, staff office, living room, kitchen,a dining room, a lounge area, a community room, an attached garage which is the activity room, a washer and dryer near the kitchen and and 2 outdoor shaded areas.

Between the hours of 11:52am - 12:30pm, LPA conducted a records review of (4) client records, (2) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

Between the hours of 11:26 am - 11:51am, LPA and Kenya Brown toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair.

Report continues on LIC 809-C.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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: SMITH FAMILY RESIDENTIAL CARE
FACILITY NUMBER: 198320144
VISIT DATE: 02/19/2025
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Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F (water measured at 108.8).

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with Kenya Brown, Administrator

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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