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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320488
Report Date: 07/22/2024
Date Signed: 07/22/2024 11:04:08 AM

Document Has Been Signed on 07/22/2024 11:04 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:GARDENIA HOMEFACILITY NUMBER:
198320488
ADMINISTRATOR/
DIRECTOR:		CHILDS, LA VIDAFACILITY TYPE:
735
ADDRESS:510 WEST 169TH STREETTELEPHONE:
(310) 400-7619
CITY:GARDENASTATE: CAZIP CODE:
90248
CAPACITY: 4CENSUS: DATE:
07/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Latiesha Martin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 7/22/24 Licensing Program Analyst (LPA), Felisa Shirley conducted an announced visit to the above facility for purpose of a pre-licensing evaluation. During the inspection LPA toured the inside and outside of the facility.

An application was submitted to CCLD on 4/17/24, for an initial application for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18 to 59 years. The requested capacity is for 4 clients, all ambulatory. Facility has a fire clearance for 4 ambulatory.

Structure: Facility is a 4 client-bedroom, 1 office, 2-bathroom, one-story house. The client bedrooms are spacious and easily accommodate the client's furnishings. There is a back yard with a shaded patio area and chairs. Shaded area has sufficient tables and chairs for clients. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility.

Bedrooms Residents: Facility has 4 ambulatory bedrooms. Bedrooms 1 thru 4 has one bed, one chair, night stand, dresser, ample lighting, and closet. Bedroom 5 will be used as an office.

Office: Facility has an office that has a bed currently but will be converted to an office which will store a locked file cabinet for both staff and resident files.

Bathrooms: Facility has two bathrooms. Both bathrooms were observed to have working toilets, wash basins and showers. LPA observed adequate lighting in hallway leading to bathrooms.

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, and pillow cases.



Con'd on 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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: GARDENIA HOME
FACILITY NUMBER: 198320488
VISIT DATE: 07/22/2024
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Emergency Phone Numbers, Exit Plan: The telephone, which is a land line, was called by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on the wall in the dining room. A fully charged fire extinguisher was found in the kitchen and in the garage.

Food Service: Dishes, cups and flatware are stored in the kitchen drawers, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet under the sink in the kitchen. Food supply was adequately stored in kitchen refrigerator and cabinets and consists of the following: a variety of fresh and canned fruit, vegetables and meats.

Smoke Detectors: Smoke and carbon monoxide detectors are hardwired and interconnected. All were operational.



Appliances: Stove burners, oven, microwave, washer, and dryer located in the kitchen are working. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.

Toxins: Locked/stored in cabinet located in the hallway.

Medications, First-Aid Kit & Book: Area for medication storage is in kitchen locked in an upper cabinet. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to clients.

Clients & Staff Files: LPA saw what will be accessible to designated staff. Records of staff and clients shall be stored in office cabinet.

Games and activities: The facility has games, and other recreational materials for the client's use.

Pool/Jacuzzi & Pets: LPA did not observe any pet or bodies of water at the facility.


Con'd on 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GARDENIA HOME
FACILITY NUMBER: 198320488
VISIT DATE: 07/22/2024
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Fire clearance: Fire Clearance was approved on 5/9/24 for 4 ambulatory clients. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.

Component III: Conducted at the Pre-Licensing visit, on 07/22/24 at Gardenia Home. Information provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection no items were observed which do not comply with applicable laws and regulations; no items require a follow up inspection for verification of correction.

Pre-Licensing is complete and this facility has no deficiencies.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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