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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320357
Report Date: 07/11/2024
Date Signed: 07/11/2024 11:12:46 AM

Document Has Been Signed on 07/11/2024 11:12 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:SERRA PROJECT LONG BEACHFACILITY NUMBER:
198320357
ADMINISTRATOR/
DIRECTOR:
MANCILLA, CHRISTINAFACILITY TYPE:
736
ADDRESS:638 SUNRISE BLVD.TELEPHONE:
(562) 595-4877
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 11CENSUS: 9DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Manager Sokha SeaTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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On 07/11/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Manager Sokha Sea as the purpose of the visit was explained. The facility is licensed to serve (11) medically fragile adults ages 18 and over of which (4) may be non-ambulatory. Current census is (9). Facility fees are current, liability insurance active with expiration date of 01/01/25.

The facility is a two-story residential home, with a two-story carriage house that has an attached (3) car garage. The front house consists of (11) resident bedrooms, (5) resident bathrooms, (1) staff bathroom, living room, kitchen, dining room, breakfast nook, and butler’s pantry. The two story carriage house serves as staff office(s), has a pantry room, and also has a laundry room with (2) washer and (2) dryer. The backyard was observed to have a table and chairs, and a wheelchair ramp. There is an additional refrigerator and freezer located in the garage as well as additional laundry and hygiene supplies. There are no weapons nor bodies of water on the premises. Bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to residents.



LPA conducted a records review of 2 staff records, 3 resident records, and 3 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 05/30/24, (9) fire extinguisher fully charged throughout the home, carbon monoxide and smoke detectors are interconnected and operational. A landline was observed.

Exit interview conducted with Manager Sokha Sea, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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