<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320187
Report Date: 06/06/2025
Date Signed: 06/06/2025 12:36:37 PM

Document Has Been Signed on 06/06/2025 12:36 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: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:
06/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:21 AM
MET WITH:Hai NguyenTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/06/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Licensee, Hai Nguyen, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve four (4) ambulatory clients of which two (2) may be non-ambulatory ages 18 through 59. Currently, there are no clients residing in the facility.
Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. It consists of four (4) client bedrooms, two (2) bathrooms, living room, dining room, kitchen, detached garage, and an outside activity area. All walkways around the facility were observed clean, clear, and free of debris, hazards, and obstructions. LPA did not observe any bodies of water on the premises.
Bedroom LPA inspected all client bedrooms. LPA observed client bedrooms were clean and in good repair. LPA observed bedrooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for client’s personal belongings. LPA observed beds are in good repair. All beds have the required
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
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: ATKINSON HOME, INC.
FACILITY NUMBER: 198320187
VISIT DATE: 06/06/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of bed linens in good repair. Bedrooms were observed with ample lighting.
Bathrooms LPA observed bathrooms met Title 22 regulations and are operable. LPA showers clean and free of mold and mildew. LPA observed storage areas for personal hygiene. LPA observed an adequate supply of towel, in good repair. The water temperature measured 111.3-degrees and 111.7-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all appliances are operable. LPA observed a sufficient amount of perishable food and non-perishable foods are maintained at the facility. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a secured area for sharps and knives, to be stored and not accessible to clients. The water temperature measured 111.4-degrees Fahrenheit.
Common Areas LPA observed the living area has a sectional sofa, recliner and table. LPA observed games and activities. The dining room has a table with chairs to accommodate clients. LPA observed the facility was appropriately furnished during time of visit. LPA observed all walkways and hallways in the facility are clear and free of obstructions and hazards. The facility was maintained at a comfortable temperature.
Safety LPA observed smoke detectors and carbon monoxide detector are operable. LPA observed a fully charged fire extinguisher. The facility has a First Aid kit with the required items and a current manual. No emergency drills have been conducted. An emergency supply of food and water is maintained at the
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ATKINSON HOME, INC.
FACILITY NUMBER: 198320187
VISIT DATE: 06/06/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
facility. The facility has a working landline telephone. LPA observed required postings posted throughout the facility.
Files The facility does not have staff or clients. No records were reviewed. The Licensee has an Administrator Certificate that is valid till 06/19/2026. LPA informed Licensee that Licensing Fees are due on 06/28/2025 and provided the PIN for online payment. The are no Centrally Stored Medications or Medication Administration Record (MAR).
Infection Control Upon entry, LPA observed a sanitizing station with a visitor log and hand sanitizer. LPA observed infection control signs posted at the entrance and throughout the facility. LPA observed a 30-supply of Personal Protective Equipment (PPE).

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Licensee, Hai Nguyen, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4