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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320294
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:53:17 PM

Document Has Been Signed on 01/07/2025 03:53 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:ACTIVE CARE HOME 1FACILITY NUMBER:
198320294
ADMINISTRATOR/
DIRECTOR:		CANTORIA, MARIA L.FACILITY TYPE:
735
ADDRESS:20545 MADISON ST.TELEPHONE:
(310) 370-3748
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 4CENSUS: 4DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Administrator - Kadiguia LinayaoTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On 1/7/2025 around 2:50 PM, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Kadiguia Linayao. CCLD staff explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection.

This facility is licensed to serve 4 adults ages 18 to 59 years old, of which 2 may be non-ambulatory and 2 maybe bedridden. The facility has an approved hospice waiver for 4 clients.

A total of 4 clients are currently residing in this facility.

Facility Layout: The facility is a one-story house located in a residential street. The home consists of 4 client bedrooms, 1 office room, 3 full bathrooms, 2 living room areas, 1 dining room area, 1 kitchen area, 1 storage room, 1 attached garage with a laundry area, 1 backyard patio area with shaded seating and a gazebo with shaded seating.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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 3
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: ACTIVE CARE HOME 1
FACILITY NUMBER: 198320294
VISIT DATE: 01/07/2025
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Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises.

Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to clients in care. There is fire extinguisher in the kitchen area and it was last serviced on 12/23/2024. There is a landline telephone on the kitchen countertop.

Living Room/TV Room: There is a videoconferencing device, and games/activity work (i.e. board games, books, magazines, and coloring books) for clients. There are couches and chairs for clients to sit at.

Client Bedrooms: 4 out of 4 client bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition.

Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to clients.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: ACTIVE CARE HOME 1
FACILITY NUMBER: 198320294
VISIT DATE: 01/07/2025
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Miscellaneous: First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

Due to time constraints the department was unable to complete annual inspection.

No deficiencies were cited.

An exit interview was conducted, and a copy of this report was left with the Administrator.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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