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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320321
Report Date: 02/13/2025
Date Signed: 02/13/2025 01:38:13 PM

Document Has Been Signed on 02/13/2025 01:38 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ATAP RESIDENTIAL HOMEFACILITY NUMBER:
198320321
ADMINISTRATOR/
DIRECTOR:		WATERS, CORIFACILITY TYPE:
735
ADDRESS:11543 S. VAN NESS AVENUETELEPHONE:
(310) 292-8018
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 4CENSUS: 4DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee/Administrator - Cori WatersTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 2/13/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator, Cori Waters. CCLD staff explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection.

This facility is licensed to serve 4 ambulatory adults ages 18 to 59 years old.

A total of 4 clients are currently residing in this facility.

Facility Layout: The facility is a one-story house located on a main street. The home consists of 4 client bedrooms, 2 full bathrooms, 1 living room area with a dining table, 1 kitchen area with a laundry area, and 1 backyard patio area with shaded seating.

Outside Grounds: were toured and walkways around facility were clear of hazards.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ATAP RESIDENTIAL HOME
FACILITY NUMBER: 198320321
VISIT DATE: 02/13/2025
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Kitchen Area: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to clients in care. There is fire extinguisher in the kitchen.

Living Room: There is a landline telephone, and games/activity work (i.e. board games and card games) for clients in the living room area. There are couches and chairs for clients to sit at.

Client Bedrooms: 4 out of 4 client bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition.

Bathrooms: Toilets, showers, and water faucets worked properly, water temperature measured 120 F. Adequate lighting and toiletries accessible to clients.

Medications: were inaccessible to clients in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 1 out of 4 Medication Administration Records (MARs) were reviewed and they were current and up to date.

Miscellaneous: Documents are posted as mandated. Last disaster drill was conducted on 2/5/2025. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ATAP RESIDENTIAL HOME
FACILITY NUMBER: 198320321
VISIT DATE: 02/13/2025
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5 staff records were reviewed, 5 out of 5 staff records had required documentation.

4 client records were reviewed and, 4 out of 4 client records had required documentation.

A technical violation is being provided regarding a video-conferencing device.

No deficiencies are being cited based observation and record review in accordance with the California Code of Regulations, Title 22.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
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