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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320157
Report Date: 03/22/2024
Date Signed: 03/22/2024 09:29:27 AM

Document Has Been Signed on 03/22/2024 09:29 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:NASHARI RESIDENTIAL CAREFACILITY NUMBER:
198320157
ADMINISTRATOR:CLARKE, ZOIEFACILITY TYPE:
735
ADDRESS:10779 CAPISTRANO AVENUETELEPHONE:
(310) 627-9208
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 4CENSUS: 4DATE:
03/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator/Licensee - CLARKE, ZOIETIME COMPLETED:
10:00 AM
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On 03/22/2024 at around 8:00 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with a staff member. LPA explained the purpose of the visit and was accompanied by Administrator inside and outside the facility during this inspection.

The facility has a balance of $454 of Annual Licensing Fees due on 03/29/2024.

The facility is a one-story house located in a residential street. The home consists of 3 client bedrooms, 2 bathrooms, 1 living room, 1 office, 1 kitchen, 1 detached garage, and 1 backyard patio area with shaded seating.

Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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: NASHARI RESIDENTIAL CARE
FACILITY NUMBER: 198320157
VISIT DATE: 03/22/2024
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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 earthquake drill was conducted on 02/10/2024 and the last fire drill was conducted on 03/02/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There are two fire extinguishers in the facility, and they were last serviced on 02/09/2023. There are two landline telephones and there is a videoconferencing device dedicated for client use in the facility .

3 out of 3 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. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.
3 client records were reviewed and, 3 out of 3 client records had required documentation.

No deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted and the copy of this report was left with the staff member.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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