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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600561
Report Date: 06/18/2025
Date Signed: 06/19/2025 07:30:16 AM

Document Has Been Signed on 06/19/2025 07:30 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:JR RESIDENTIAL CAREFACILITY NUMBER:
198600561
ADMINISTRATOR/
DIRECTOR:		HARRISON, JANICEFACILITY TYPE:
735
ADDRESS:4565 WEST 167TH STREETTELEPHONE:
(310) 542-2360
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 4CENSUS: 4DATE:
06/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Sarita Wellington, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:09 PM
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 On 6/18/25, Licensing Program Analyst (LPA) Felisa Shirley arrived unannounced to conduct an Annual Required - 1 Year Inspection and met with Administrator Assistant, Sarita Wellington. LPA disclosed the purpose of the inspection was granted entry into facility. The current census is 4.

Walk through inspection was conducted by LPA Shirley and Sarita inside and outside to ensure that there are no health and safety hazards.

DINING ROOM: LPA Felisa and Sarita inspected the dining room and found it to be clean and all the furniture was in good working order. There were adequate number of chairs and a place at the table for all residents in the facility.

KITCHEN: LPA Shirley observed the kitchen to be clean and sanitary and all appliances were operable. Knives were properly secured and inaccessible to persons in care. The facility has a sufficient supply of perishable and non-perishable foods. LPA Shirley noted that the water temperature delivered at 108.2 F.

LIVINGROOM: LPA Shirley and Sarita inspected the Livingroom. LPA observed it to be clean and free of dirt. There were working lights, a working landline phone, and no fireplace or open face heating.

BEDROOMS: LPA Shirley and Licensee inspected the bedrooms. There are 4 bedrooms. Three bedrooms for the residents and 1 room for the staff. The resident’s bedrooms have accommodating chairs and dressers for every resident.

Con'd on 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: JR RESIDENTIAL CARE
FACILITY NUMBER: 198600561
VISIT DATE: 06/18/2025
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BATHROOM: LPA Shirley and Sarita toured both bathrooms. LPA found the bathrooms to be clean, paper towels and soap. There was functioning toilet with handrails and shower.

BACKYARD: LPA Shirley and Sarita inspected the backyard and found it to be clean and a shaded area for the residents. LPA observed that there was no pool or bodies of water.

GARAGE: LPA Shirley observed that the garage is used for both the office and storage room. A refrigerator, extra food and supplies were observed. LPA observed the washer and dryer and they were in working order.

LPA Shirley found there to be several hardwired smoke/carbon monoxide detectors in the facility. 1 in the hallway, 1 in the kitchen and Livingroom, 1 in every bedroom. LPA found that the hallway was clear of any obstructions.

LPA Shirley found there to be 1 fully charged fire extinguisher located in the kitchen. It is maintained and serviced yearly. Inspection record was up to date and tags visible.

All medications were secured in a locked cabinet located in the garage. LPA checked resident MAR with labeled medications. LPA found there to be a fully stocked first aid kit with an up-to-date Red Cross manual.

LPA Shirley reviewed all client files and found that they contained all required documents. LPA reviewed 4 staff Personal files, and LIC 500 and found that all staff are associated with our records in Guardian.

There were no deficiencies issued.

An Exit interview was conducted, and a copy of this report was discussed and left with Sarita Wellington, whose signatures on this form confirm receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
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