198320321-2-13-2023-11-AS-WGIS-CN9QCL-20230120110319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320321
Report Date: 01/20/2023
Date Signed: 02/13/2023 03:14:39 PM

Document Has Been Signed on 02/13/2023 03:14 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:	ATAP RESIDENTIAL HOME		FACILITY NUMBER:	198320321
ADMINISTRATOR:	WATERS, CORI		FACILITY TYPE:	735
ADDRESS:	11543 S. VAN NESS AVENUE		TELEPHONE:	(310) 292-8018
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 4		CENSUS: 0	DATE:	01/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Cori Waters		TIME COMPLETED:	11:15 AM

NARRATIVE

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On January 20, 2023, Licensing Program Analyst (LPA), Wendy Gibbs, met with Licensee, Cori Waters, to conduct a pre licensing visit. The facility has requested a change of address, with the capacity of 4 residents. The fire safety inspection was cleared for four (4) ambulatory residents.

Structure The facility is a one-story house in a residential neighborhood. The facility consists of Four (4) bedrooms, two (2) bathrooms, a kitchen, dining room and living room.

Physical Plant LPA walked through the facility inside and out. The front is landscaped and maintained. The back yard in well maintained. There is a shaded area with table and chairs available for resident. There is a detached garage that is not used by the facility and inaccessible to all but the owner. No bodies of water were observed. All walkways are clear of obstructions, hazards and debris. All exits are accessible and easy to open from the inside.

Bedroom There are four (4) resident bedrooms. Each room contained the required furniture, including a bed, dresser, nightstand with a lamp, and a chair. All beds have the required linens including a mattress pad, fitted sheets, blanket, comforter and pillow. All rooms have ample closet space and lighting.

Bathrooms All bathrooms were inspected. The sink, toilet and shower were in good working order. The showers were free of mold and mildew and had a nonskid mat. There is an ample supply of lighting, hand soap and paper towels. Both bathrooms meet title 22 regulations. The water temperature measured 111.8- to 115.3- degrees Fahrenheit.

Linens & Hygiene Provided for each client is a container that has toiletries, including shampoo, body wash, brush, lotion, toothbrush, toothpaste, and deodorant. An ample supply of towels, sheets, blankets, and additional hygiene supply are stored in the hall closet.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ATAP RESIDENTIAL HOME	FACILITY NUMBER: 198320321
	VISIT DATE: 01/20/2023

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Kitchen All appliance in the kitchen were in good working condition. They consist of a dishwasher, microwave, stove/oven, refrigerator, washer, and dryer. All cutleries were in good condition. LPA observed a 7-day supply of nonperishable and a 3-day supply of perishable foods. Sharps are locked in a drawer in the kitchen. Toxins are stored in the locked cabinet under the sink. The water temperature measured at 117.6- degrees Fahrenheit.

Common Areas The dining room consist of a round table and 4 chairs. The living room has ample seating for all residents. All rooms have ample lighting. All walkways are clean, clear, and free of obstructions and hazards.

Safety LPA observed 7 functioning smoke/carbon monoxide detectors and 2 additional carbon monoxide detectors. There is a fire extinguisher mounted on the wall in the kitchen. LPA found the landline to be functioning. All exits are marked and all emergency documents are posted. LPA observed a First Aid Kit and manual.

Infection Control There is a sanitizing station at the entrance of the facility. It contains a thermometer, log, hand sanitizer and masks. All infection control signs are posted throughout the facility. LPA observed a 30 day supply of PPEs.

Knives and Toxins Knives are stored in a locked drawer in the kitchen. Cleaning supplies are stored and locked under the sink and additional cleaning supplies are locked in the closet in the hallway.

Medication and Files Medications will be stored in a locked cabinet in the kitchen. Files will be stored and in a locked cabinet in the kitchen, just above the medication cabinet.

Component III The licensee read through Component III and had no questions.

There are no advisory notes.

LPA conducted a final interview with the Licensee, Cori Waters and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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