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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600561
Report Date: 06/21/2023
Date Signed: 06/21/2023 12:39:47 PM

Document Has Been Signed on 06/21/2023 12:39 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:JR RESIDENTIAL CAREFACILITY NUMBER:
198600561
ADMINISTRATOR:HARRISON, JANICEFACILITY TYPE:
735
ADDRESS:4565 WEST 167TH STREETTELEPHONE:
(310) 542-2360
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 4CENSUS: 4DATE:
06/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:House manager Sarita GenusTIME COMPLETED:
03:00 PM
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On 06/21/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Sarita Genus as the purpose of today’s visit was explained. The facility is licensed to serve one (1) ambulatory and three (3) non-ambulatory developmentally disabled adults ages 18-59. Residents are linked to the Westside regional center.
The facility is a single-story structure located in a residential neighborhood and consists of the following: three (3) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living area, dining area, kitchen, an outdoor shaded activity area, and an attached garage that serves as a pantry, laundry area, staff office and a staff refrigerator.
LPA conducted a records review of one (1) staff record, two (2) resident records and two (2) Medication Administration Records, LPA did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 06/09/23, one(1) fire extinguishers fully charged, carbon monoxide detectors observed, smoke detectors are operational, and a landline was observed.
All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathrooms were found to be within Title 22 regulation, 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..
Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.
During today’s visit no discrepancies were observed. Exit interview conducted with House manager Sarita Genus, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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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