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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320321
Report Date: 02/29/2024
Date Signed: 02/29/2024 11:56:42 AM

Document Has Been Signed on 02/29/2024 11:56 AM - 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:
02/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:Dominique LauderdaleTIME COMPLETED:
12:20 PM
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 On 02/29/2024, Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced annual required visit using the Care Inspection Tool. LPA Richard met with lead staff Dominique Lauderdale. LPA explained the purpose of today's visit. The facility is licensed to serve four (4) ambulatory residents. The fire safety inspection was cleared for four (4) ambulatory residents.

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 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.

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.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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: ATAP RESIDENTIAL HOME
FACILITY NUMBER: 198320321
VISIT DATE: 02/29/2024
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All bathrooms were inspected. The sink, toilet and shower were in good working condition. 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 hot water temperature measured 106.7F- to 108.6F- degrees Fahrenheit. An ample supply of towels, sheets, blankets, and additional hygiene supply are stored in the hall closet. All appliance in the kitchen were in good working condition. They consist of a dishwasher, microwave, stove/oven, refrigerator, washer, and dryer. 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 living room has ample seating for all residents. All rooms have ample lighting. All walkways are clean, clear, and free of obstructions and hazards.

LPA observed 7 functioning smoke/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. There is a sanitizing station at the entrance of the facility. It contains a thermometer, log, hand sanitizer and masks. LPA observed a 30 day supply of PPEs. 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. Medications stored in a locked cabinet in the kitchen.

No deficiencies. Exit interview conducted and a copy of this report was provided to lead staff Dominique Lauderdale.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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