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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320339
Report Date: 11/08/2023
Date Signed: 11/14/2023 01:52:37 PM

Document Has Been Signed on 11/14/2023 01:52 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:PRIORITY ONE ADULT RESIDENTIALFACILITY NUMBER:
198320339
ADMINISTRATOR:TALLEY, CHANDRAFACILITY TYPE:
735
ADDRESS:13512 S. ARDATH AVENUETELEPHONE:
(310) 354-3927
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 4CENSUS: 3DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dennis Cooper, SupervisorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit. LPA met with Dennis Cooper, Supervisor and the purpose of this visit was explained. There are currently three (3) residents in placement.

The facility is a single-story home in a residential neighborhood with a driveway. The facility consists of a living room, dining room, kitchen, four (4) bedrooms, two (2) full bathrooms, and an attached garage.

LPA Shirley and Dennis walked through all four (4) rooms. Bedrooms 1-4 are designated for the resident’s individual use. All bedrooms contained a bed and chair with ample lighting and closet space.

LPA Shirley and Dennis walked through the kitchen and all appliances were in good working order. Knives were locked and stored under the sink in the kitchen and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured at 118.9 degrees Fahrenheit.

All bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly. The showers were free of mildew and mold. LPA Shirley and Dennis walked through the laundry area, all cleaning products were locked in a cabinet and inaccessible to residents.

LPA Shirley and Dennis walked through all common areas. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms and the hallway had smoke detectors. There is a fully charged fire extinguisher in the kitchen.

LPA Shirley and Dennis walked the outside of the facility. In the back yard there is a table, chairs and umbrella for residents and visitors use. All walkways were clear of debris, obstructions and hazards. LPA did not observe any bodies of water.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report provided to the supervisor Dennis Cooper.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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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