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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600956
Report Date: 05/05/2023
Date Signed: 05/05/2023 11:49:39 AM

Document Has Been Signed on 05/05/2023 11:49 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:PRISCILLA'S HOMEFACILITY NUMBER:
198600956
ADMINISTRATOR:BETH KAZUYE FIGUEROAFACILITY TYPE:
735
ADDRESS:2505 WEST 180TH STREETTELEPHONE:
(310) 538-9978
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 4CENSUS: 4DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:16 AM
MET WITH:PATRICK FIGUEROATIME COMPLETED:
12:00 PM
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On 05/05/23 at 8:16 AM Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual required visit using the New Care Inspection Tool. LPA was met with Licensee Patrick Figueroa . the purpose of today’s visit was explained. There are currently (4) Regional Center consumers in placement. All (4) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 2 bathrooms, family room/office, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and attached garage.

LPA and Licensee toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1 –4 are occupied by clients and contain the mandated furniture, bedroom 5 is occupied by staff. The (2) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector are in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. All staff files are current. All resident files are current along with medications. The hot water temperature in the bathroom tested at 119.09F degrees. A comfortable temperature is maintained in the facility. Adequate supply of perishable and nonperishable food, linens and personal hygiene were observed. Hazardous toxins and/or items are inaccessible to clients, 2 fire extinguishers are fully charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in the staff bathroom and additional sanitation supplies in a locked cabinet. LPA observed staff and clients wearing masks, clients can isolate in their room if necessary required postings throughout the facility.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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: PRISCILLA'S HOME
FACILITY NUMBER: 198600956
VISIT DATE: 05/05/2023
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 LPA observed that sanitizer is administered to clients based on level of functioning with the supervision of staff. The facility has an approved Mitigation plan. Visitors are logged and checked. The client’s temperatures are checked and logged 2x a day. The facility liability insurance is current.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted and a copy of report was provided to Licensee Patrick Figueroa.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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