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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320339
Report Date: 11/18/2024
Date Signed: 11/21/2024 12:27:32 AM

Document Has Been Signed on 11/21/2024 12:27 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:PRIORITY ONE ADULT RESIDENTIALFACILITY NUMBER:
198320339
ADMINISTRATOR/
DIRECTOR:		PLUMMER, MICHELLEFACILITY TYPE:
735
ADDRESS:13512 S. ARDATH AVENUETELEPHONE:
(310) 354-3927
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 4CENSUS: 4DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Chandra Talley, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 11/18/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Chandra Talley and explained the purpose of today’s visit. The facility is licensed to serve developmentally disabled residents ages 18 to 59 years old, cleared for four (4) ambulatory residents.

LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, training, and certification. LPA reviewed the surety bond. LPA reviewed the training logs for staff.

LPA Felisa and Dennis toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (2) bathroom, living room, kitchen, dining area and patio. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Dennis toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored in the hallway closet. The medications were locked and stored in a closet located in the hallway and inaccessible to the resident. The washer and dryers are in good working condition are located in the kitchen. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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: PRIORITY ONE ADULT RESIDENTIAL
FACILITY NUMBER: 198320339
VISIT DATE: 11/18/2024
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The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Dennis walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.


An exit interview was conducted, and a copy of this report was provided to the Supervisor, Dennis Cooper
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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