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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600715
Report Date: 06/24/2023
Date Signed: 08/08/2023 09:38:32 AM

Document Has Been Signed on 08/08/2023 09:38 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WRIGHT RESIDENTIAL HOME IV, THEFACILITY NUMBER:
198600715
ADMINISTRATOR:TIMS, RENEEFACILITY TYPE:
735
ADDRESS:9447 SOUTH HARVARD BLVD.TELEPHONE:
(323) 756-2090
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 4DATE:
06/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adrienne GallowayTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Administrator Adrienne Galloway and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. The facility is vendored with South Central Los Angeles Regional Center (SCLRC). LPA Bunker verified that the administrator is present at the property 20+ hours per week, and all current staff was fingerprinted and cleared/associated with the facility. The facility's annual fees are current. The facility currently has four (4) ambulatory South Central Los Angeles Regional Center (SCLARC) consumers in placement.

The following Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a single-story family home located in a residential neighborhood. Ms. Galloway and LPA Bunker made a complete tour of the facility which included: Living room, dining room, kitchen, pantry, 4 bedrooms, 2 bathrooms, medication area, laundry area, storage room, detached garage, patio/shaded area, indoor/outdoor activity areas. See attached LIC 809-C on page #2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WRIGHT RESIDENTIAL HOME IV, THE
FACILITY NUMBER: 198600715
VISIT DATE: 06/24/2023
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Continued LIC809-C page #2

Documents were posted as mandated on the wall in the hallway. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with a manual, the hot water temperature was measured at 120 degrees Fahrenheit, the telephone is working, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the hallway cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on June 01, 2023. No firearms on the premises, the client's bedroom windows have no sliding window lock with thumbscrew, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

Ms. Galloway states staff was given training on dependent adult and elder abuse reporting. The administrator certificate is current and expires on 11/29/2023 and HIV/TB certification is also current.

There were no deficiencies cited. LPA Bunker provided Administrator Adrienne Galloway with copies of the LIC809, LIC809-C, LIC858, and LIC859 documents.

An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023
LIC809 (FAS) - (06/04)
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