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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320180
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:47:55 PM

Document Has Been Signed on 04/18/2024 03:47 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:2NTHESAME HOMEFACILITY NUMBER:
198320180
ADMINISTRATOR/
DIRECTOR:		WILSON, DARLENEFACILITY TYPE:
735
ADDRESS:622 CYPRESS STREETTELEPHONE:
(310) 714-4006
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 3CENSUS: 0DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Licensee/Administrator - Marlene WilsonTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 04/18/2024 at around 2:50 PM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator Marlene Wilson. LPA explained the purpose of the visit and was accompanied by the Licensee inside and outside the facility during this inspection.

This facility is licensed to serve 3 ambulatory adults ages 18 – 59 years.
A total of 0 ambulatory clients are currently residing in this facility.
The facility has a balance of $454 in annual licensing fees due on 04/29/2024.

The facility is a two-story house located in a residential street. The home consists of 3 client bedrooms, 2 bathrooms, 1 living/dining/kitchen area, 1 attached 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 security bars on the premises.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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: 2NTHESAME HOME
FACILITY NUMBER: 198320180
VISIT DATE: 04/18/2024
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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.

Documents are posted as mandated. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

3 out of 3 clients’ 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.

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

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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