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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320304
Report Date: 08/14/2023
Date Signed: 08/14/2023 03:47:50 PM


Document Has Been Signed on 08/14/2023 03:47 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:KINAH MAE HOME LLCFACILITY NUMBER:
198320304
ADMINISTRATOR:WHITFORD, WALKIRIAFACILITY TYPE:
740
ADDRESS:1420 W. 186TH ST.TELEPHONE:
(310) 720-7080
CITY:GARDENASTATE: CAZIP CODE:
90248
CAPACITY:6CENSUS: DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Daisy SamparaniTIME COMPLETED:
04:00 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
Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit with a primary focus on Infection Control measures using the CARE Inspection Tools. LPA met with Staff Daisy Samparani, and the purpose of this visit was explained. There are currently six (6) residents in placement.

The facility is a single-story home situated in a residential neighborhood with a driveway. The facility consists of a living room, family room, dining room, kitchen, four (4) bedrooms, two (2) full bathrooms, living room, dining room, kitchen and laundry area.

LPA walked through all four (4) rooms. Bedrooms 1 - 4 are designated for the resident’s individual use. All bedrooms contained a bed, dresser, nightstand, chair. Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. All bedrooms are equipped with a ceiling light. All rooms had a dresser/storage area, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage.

The home has two (2) bathrooms. Bathrooms are adjacent to each bedroom. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats. The water delivers at 115.1 F.



The kitchen counters also had small appliances. Stove burners, oven, microwave, washer, and dryer are working. Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer. Food supply is adequately stored in kitchen cabinets and consists of boxed and can goods. The home is equipped with central heaters and air conditioning systems.

Smoke and carbon monoxide detectors are throughout the interior space. All toxins are locked and stored under the kitchen sink cabinet and in the garage.

Con'd on 809-C
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KINAH MAE HOME LLC
FACILITY NUMBER: 198320304
VISIT DATE: 08/14/2023
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
A first aid kit is stored in the facility with a first aid manual.

The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions.

LPA observed no deficiencies that needed to be corrected.

An exit interview was conducted, and a copy of this report has been furnished to the administrator, Walkiria Whitford.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2