198320304-8-5-2024-11-AS-FSHY-D7UUMM-20240805154233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320304
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:42:41 PM

Document Has Been Signed on 08/05/2024 03:42 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:	KINAH MAE HOME LLC		FACILITY NUMBER:	198320304
ADMINISTRATOR/ DIRECTOR:	WHITFORD, WALKIRIA		FACILITY TYPE:	740
ADDRESS:	1420 W. 186TH ST.		TELEPHONE:	(310) 720-7080
CITY:	GARDENA	STATE: CA	ZIP CODE:	90248
CAPACITY: 6		CENSUS: 6	DATE:	08/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:10 PM
MET WITH:	Walkiria Whitford, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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On 08/5/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Walkiria Whitford and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 60 years and older, cleared for six (6) non-ambulatory residents of which one (1) may be bedridden. During the time of visit all six (6) residents were present.

LPA reviewed four resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, and trainings. LPA reviewed their Liability Insurance. LPA reviewed the training logs for staff.

LPA Shirley and Walkiria toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (2) bathrooms, living room, kitchen, den and dining area, patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms and hallways.

LPA Shirley and Walkiria toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored and inaccessible to the resident. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 112 degrees Fahrenheit.

con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

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: KINAH MAE HOME LLC	FACILITY NUMBER: 198320304
	VISIT DATE: 08/05/2024

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The (2) bathrooms have grab bars and are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Walkiria walked through all common areas. In the living room, and dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen and hallway. The backyard is shaded, clean and clear of obstructions and hazards, and there are no bodies of water present.

LPA Shirley did not observe any deficiencies.

An exit interview was conducted, and a copy of this report was provided to Administrator, Walkiria Whitford.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

LIC809 (FAS) - (06/04)

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