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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600586
Report Date: 10/02/2025
Date Signed: 10/02/2025 02:05:20 PM

Document Has Been Signed on 10/02/2025 02:05 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:KINDWEILER HOMEFACILITY NUMBER:
198600586
ADMINISTRATOR/
DIRECTOR:		GAMIO, CLAUDIA V.FACILITY TYPE:
735
ADDRESS:272 EAST 213TH ST.TELEPHONE:
(310) 999-8666
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 3DATE:
10/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Claudia GamioTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On October 2, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Claudia Gamio. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory Developmental Disable Adults 18 through 59. The clients are all Harbor Regional Center consumers.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: (4) client's rooms, (2) bathroom, (2) staff room (1) staff bathroom, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 119.2 degrees F. A comfortable temperature of 72 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. The last Emergency Fire Drill was conducted on 09/16/25. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

(Evaluation Report continues LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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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Document Has Been Signed on 10/02/2025 02:05 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/02/2025 at 12:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINDWEILER HOME
FACILITY NUMBER: 198600586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in (3) out of (3) objects identified that need to be repaired. No window blinds for kitchen window, no bedroom door for vacant room, stove burners not operating properly and must be ignited with a match. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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Administrator will ensure that the facility is in good repair and must repair the following: bedroom door for vacant room, blinds for kitchen window, and kitchen stove burners must operate without igniting a match. POC is due 11/03/25 with photos or videos sent to LPA ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interviw , the licensee did not comply with the section cited above. The facility does not have a current certificed licensed administrator. This violatio which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licensee will ensure to renew certification of administrator license with CCL. POC is due 10/16/25 to LPA ernand.dabuet@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2025 02:05 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/02/2025 at 12:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINDWEILER HOME
FACILITY NUMBER: 198600586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section. LPA identified staff #3 is not associated into the facility. Staff does not show up in Guardian or LIS for this facility. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Administrator shall ensure that transfer request documents are submitted to CCLD for association. Documents that need to be submitted include: A signed Criminal Background Clearance, Transfer Request, LIC 9182, and a valid govt issued picture ID/CAL. Due to LPA by POC dates. ***civil penalty assessed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


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: KINDWEILER HOME
FACILITY NUMBER: 198600586
VISIT DATE: 10/02/2025
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has a Surety Bond coverage expires 02/03/29 with policy #25297360. The facility is current with commercial liability insurance coverage with policy #B1D03472505 effective 07/09/25 through 07/09/26.

An audit of clients #1-#3 (C1-C3) service files and staff #1-#4 (S1-S4) personnel files revealed to be order. An audit of the client's P&I is maintained in order and complete.

Deficiencies:
The following were observed/identified during physical inspection visit:
  • Kitchen stove top burners - not working properly and must be ignited with a match to operate.
  • Kitchen window has no blinds for privacy.
  • Bedroom door for vacant room missing.
  • No current certified administrator on file. Administrator certificate expired August 2025.
  • Staff #3 has no Criminal Clearance Background Transfer Association LIC 9182 with this facility.
  • (2) Technical Advisory Violations (see LIC 9102)

According to the California Code of Regulations (Title 22, Division 6, Chapter 1 & 6), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Claudia Gamio and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC809 (FAS) - (06/04)
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