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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320267
Report Date: 10/30/2024
Date Signed: 10/30/2024 10:31:12 AM

Document Has Been Signed on 10/30/2024 10:31 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:185THFACILITY NUMBER:
198320267
ADMINISTRATOR/
DIRECTOR:		LOPEZ, EVELINFACILITY TYPE:
737
ADDRESS:1436 W. 185TH ST.TELEPHONE:
(424) 559-5300
CITY:GARDENASTATE: CAZIP CODE:
90248
CAPACITY: 3CENSUS: 3DATE:
10/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Evelin Lopez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analysts (LPA) Felisa Shirley made an announced visit and met with applicant/ administrator Evelin Lopez to conduct a Pre-Licensing evaluation. The requested capacity is for six (3) ambulatory clients.

Structure: Facility is a one story family home with three bedrooms, two (2) full bathrooms, living room, dining area, kitchen, washer and dryer appliances are located in a closet off of the living room. Locked file cabinets located in the garage which is being used as an office will be used to store client and staff files. First aid kit, and first aid manual will be located in the kitchen in a locked cabinet. There are two exits, main exit is located in living room, and exit two (2) is located off of the dining room. Front yard landscape is in good condition at time of visit. Bedroom Residents: Bedrooms are equipped with one bed per client, nightstand or side table, and a chair. LPA observed activities available for clients. Bathrooms: Two (2) bathrooms have a working toilet, wash basin, and a bathtub/ shower, LPA observed grab bars and non-slip strips. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. One (1) fully charged fire extinguisher located between the kitchen and dinning room, hall closet and in the garage. LPA observed sufficient hygiene supplies for clients.

Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer in the kitchen. Smoke Detectors/Carbon Monoxide(s): Facility is equipped with operational smoke detectors in all bedrooms and mounted on the ceiling. There is one working landline located in the home.

LPA observed three day perishables, and seven days plus supply of non-perishable food.

Appliances: Stove burners, oven, microwave, and washer/dryer are in working condition. There is one working (1) refrigerator in the home and one (1) freezer and extra refrigerator located in the garage.



Cont'd on 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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: 185TH
FACILITY NUMBER: 198320267
VISIT DATE: 10/30/2024
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Component III was reviewed with applicant/ administrator Evelin Lopez, who is familiar with tittle 22 regulations.

During the pre-licensing inspection zero (0) items were observed that didn’t comply with applicable laws and regulations.

LPA reminded applicant the following items shall be posted always: Emergency numbers, Personal rights, Emergency Disaster Plan, Complaint Procedures, and facility sketch show emergency exits.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst. Applicant advised to contact LPA when first clients becomes admitted to facility.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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