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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320187
Report Date: 06/15/2024
Date Signed: 06/15/2024 03:52:27 PM

Document Has Been Signed on 06/15/2024 03:52 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:ATKINSON HOME, INC.FACILITY NUMBER:
198320187
ADMINISTRATOR/
DIRECTOR:		NGUYEN, HAIFACILITY TYPE:
735
ADDRESS:16221 S ATKINSON AVETELEPHONE:
(310) 678-6784
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 0DATE:
06/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:31 AM
MET WITH:HAI NGUYEN,& MARIA QUANTIME VISIT/
INSPECTION COMPLETED:
10:31 PM
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On 06/15/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Hai Nguyen. LPA explained the purpose of today’s visit. The facility is licensed to operate for (4) ambulatory of which may be (2) non-ambulatory adults ages 18 through 59. Currently, the facility has no clients being cared at this time.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) clients' rooms, (2) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 114.9 degrees F. A comfortable temperature of 74 F. degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately with the basic food items, bread, cereal, meats, dairy, fruits and vegetables. A fire extinguisher was charged. Currently, there is no Medication Administration Record (MAR) to audit as there are no clients.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms.
(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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: ATKINSON HOME, INC.
FACILITY NUMBER: 198320187
VISIT DATE: 06/15/2024
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LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

The facility maintained an Emergency Food supplies on hand. The facility has a First Aid kit available. A working landline phone was operational. No Emergency/Fire Drills have been conducted as the facility is vacant. The facility had operational smoke and carbon monoxide in bedrooms and common areas.

There is no audit of clients service files or personnel files as the facility is vacant. The facility has the current Administrator's Certification on file for Hai Nguyen #732679735 Exp. 06/19/24. The facility is current with CCL annual dues.

No deficiencies during this inspection visit.

An exit interview was conducted with Hai Nguyen a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024
LIC809 (FAS) - (06/04)
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