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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320239
Report Date: 02/02/2024
Date Signed: 02/02/2024 11:34:18 AM

Document Has Been Signed on 02/02/2024 11:34 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:HISGRACE COTTAGEFACILITY NUMBER:
198320239
ADMINISTRATOR:LEWIS, KRISTAFACILITY TYPE:
735
ADDRESS:1656 W 131ST STREETTELEPHONE:
(310) 573-5840
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 6CENSUS: 0DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Krista Lewis - Licensee/AdministratorTIME COMPLETED:
11:40 AM
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On 02/02/2024 at around 9:40 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Licensee/Administrator Krista Lewis and explained the purpose of the visit. LPA inspected the inside and outside of the facility.

This facility is licensed to serve 6 ambulatory adults ages 18 – 59 years.

There are currently no clients in this facility.

The facility has an outstanding balance of $454 due on 02/22/2024.

The facility is a one-story house located in a residential street. The home consists of 3 client bedrooms, 1 bathroom, 1 toilet room, 1 living/dinning room, 1 kitchen, 1 attached garage, and 1 backyard patio area with shaded seating.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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 2
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: HISGRACE COTTAGE
FACILITY NUMBER: 198320239
VISIT DATE: 02/02/2024
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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.

Documents are posted as mandated. Smoke and carbon monoxide detectors were in compliance and operational. There are two fire extinguishers in the facility, one is in the kitchen and the other is in the hallway.

1 out of 2 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. Bathroom toilets and water faucets worked properly. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit.

1 staff records were reviewed, 1 out of 1 staff record had required Criminal Record Clearance.

No deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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