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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320294
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:52:42 PM

Document Has Been Signed on 01/25/2024 02:52 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:ACTIVE CARE HOME 1FACILITY NUMBER:
198320294
ADMINISTRATOR:CANTORIA, MARIA L.FACILITY TYPE:
735
ADDRESS:20545 MADISON ST.TELEPHONE:
(310) 370-3748
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 4CENSUS: 4DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Cherry Brewer-House ManagerTIME COMPLETED:
02:50 PM
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On 1/25/2024 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Cherry Brewer /House Manager and the purpose of today’s visit was explained. The facility is licensed to operate for (4) developmentally disabled or Mentally Ill adults ages 18-59 of which (2) may be non-ambulatory and (2) bedridden.Approved hospice waiver for (4). Currently, the home has (4) clients. The clients are from: Harbor Regional Center. (0) clients have Restricted Health Care Conditions, and (3) are utilizing postural supports or protective devices. The staff to client ratio: 1-2.

The facility is a single-story house with four (4) bedrooms, three (3) full bathrooms, an office, living room, dining room, office space, kitchen, pantry and attached garage and patio with shaded area.

LPA Iniguez and house manager toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 109.4F°, Bathroom #1 109.5°F and Bathroom #2 111.5°F ).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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: ACTIVE CARE HOME 1
FACILITY NUMBER: 198320294
VISIT DATE: 01/25/2024
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Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged, toxins and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility disaster drill was:10/18/23. Administrator gave a copy of Surety Bond to LPA during the visit. Current license does not reflect approved hospice waiver for (4), LPA will update on LIS.

LPA conducted a records review of (3) client records, (3) staff records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit. Copy of liability insurance given to LPA during visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.




An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Cherry Brewer/Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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