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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600952
Report Date: 07/30/2024
Date Signed: 07/30/2024 10:29:29 AM

Document Has Been Signed on 07/30/2024 10:29 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:WASHINGTON HOME OF SACRED LIVING, THEFACILITY NUMBER:
198600952
ADMINISTRATOR/
DIRECTOR:
WASHINGTON , LENAFACILITY TYPE:
735
ADDRESS:1316 WEST 123RD STREETTELEPHONE:
(323) 777-1918
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 6CENSUS: 4DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lena Washingtonc - Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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On 07/30/2024 at 9:00AM, Licensing Program Analyst Troy Watson (LPA) conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator Lena Washington. LPA explained the purpose of the visit and was accompanied by Administrator inside and outside the facility during this inspection.

The facility is a single story structure located in a residential neighborhood. It consists of the following three (3) client rooms, two (2) bathrooms, one staff bedroom, one (1) living room area, one (1) dining area, kitchen, and outside patio area with a table and adequate amount of seating available. The facility is licensed to operate for six (6) ambulatory developmentally disabled adults between the ages of 18 through 59. A total of 2 staff and 4 clients were present during this inspection. Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. Three out of 3 client’s bedrooms ere checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries were accessible to the clients.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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: WASHINGTON HOME OF SACRED LIVING, THE
FACILITY NUMBER: 198600952
VISIT DATE: 07/30/2024
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LPA Troy Watson observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The water temperature properly measured between 106 F and 110 F in the bathrooms and in the Kitchen.

LPA Troy Watson observed the facility clean, sanitary, and appropriately furnished at the time of the visit. The kitchen, and refrigerator was fully stocked with food. The administrator has (6) smoke detectors/carbon monoxide detector that have been tested. All smoke detectors were operational. Toxins and knives were locked and inaccessible to clients. Medications were inspected and accounted for at the time of inspection. The first aid kit was checked and fully stocked with a certified manual. LPA reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. Staff records and P&I were presently available for immediate review and logged after inspection.

An exit interview was conducted, with the administrator and a copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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