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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320321
Report Date: 02/01/2024
Date Signed: 02/27/2024 12:17:11 PM

Document Has Been Signed on 02/27/2024 12:17 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:ATAP RESIDENTIAL HOMEFACILITY NUMBER:
198320321
ADMINISTRATOR:WATERS, CORIFACILITY TYPE:
735
ADDRESS:11543 S. VAN NESS AVENUETELEPHONE:
(310) 292-8018
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 4CENSUS: 4DATE:
02/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Licensee, Cori Waters TIME COMPLETED:
11:26 AM
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On 01/31/2024 at 8:26 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA was granted access and allowed to enter the facility to conduct the inspection. LPA met with Paula Stablen-House Manager and toured the facility. The facility is licensed for age range 18 through 59 approved for 4 ambulatory only. 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. LPA toured the facility with Paula Stablen-House Manager (S#1). LPA walked through the facility inside and out. 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. There are four (4) resident bedrooms. LPA interviewed Staff #1-#3 (S1-3). No deficiencies cited. Due to unforeseen circumstances an unannounced Case Management-Annual Continuation visit will be conducted. Licensing Program Manager (LPM) Ulysses Coronel provided the facility evaluation report to the Licensee, Cori Waters via electronic mail.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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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