<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600956
Report Date: 05/08/2024
Date Signed: 05/08/2024 01:13:54 PM


Document Has Been Signed on 05/08/2024 01:13 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, 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:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Teresita MarindaTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/08/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Caregiver, Teresita Miranda, and the purpose of today's visit was explained. We were later joined by designate Noel Figueroa. The facility is licensed to serve four (4) developmentally disabled clients ages 18-59. During today’s visit there were two (2) clients present.
Physical Plant/Structure The facility is a single-story house in a residential neighborhood. The facility consists of 5 bedrooms, 2 bathrooms, family room/office, living room, kitchen, dining room, indoor and outdoor activity area, laundry room and attached garage. Outside is a shaded patio with a table and chairs. LPA observed all walkways around the home to be clean, clear, and free of debris, hazards, and obstructions. There are no bodies of water on the premises.
Bedroom LPA inspected all client bedrooms and observed they are clean and in good repair. The bedrooms had the required furniture including a bed, dresser, nightstand, chair, and ample storage space for personal belongings. All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens in a cupboard in the hallway. All bedrooms had ample lighting.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PRISCILLA'S HOME
FACILITY NUMBER: 198600956
VISIT DATE: 05/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Bathrooms LPA inspected the two bathrooms and found them to be operational and in good repair. There is a shower chair for clients use. LPA observed an ample supplies of hygiene products and towels for client use. The water temperature measured 119.6-degrees Fahrenheit.
Kitchen LPA observed the kitchen to be clean and sanitary. All appliances were tested and found to be in good working repair. LPA observed an ample supply of cutleries, dishware, and cookware in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. A sample menu was posted on the refrigerator. All sharps were secured in a locked cabinet in the kitchen and are inaccessible to clients. All cleaning supplies were secured in a locked cabinet in the laundry room and are inaccessible to clients. The water temperature measured 119.8-degrees Fahrenheit.
Common Rooms In the living room, LPA observed two couches and chairs for client use. LPA observed games and activities in the family room. The dining room has a large table and chairs to accommodate all clients. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All rooms were observed with ample lighting. The facility was maintained at a comfortable temperature.
Safety Smoke and Carbon Monoxide Detectors are in compliance and are operational. LPA observed two fully charged fire extinguishers last serviced on 04/08/24. The last emergency drill was conducted on 04/17/24. The last Fire Prevention Inspection was last conducted on 03/12/23. The First Aid Kit was inspected and found to contain all required items and a manual. The facility has a working landline telephone. LPA observed all required documents posted
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PRISCILLA'S HOME
FACILITY NUMBER: 198600956
VISIT DATE: 05/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
throughout the facility. There are no firearms stored on the premises.

Files/Interview LPA reviewed all client files and found they contained the required documents. LPA interviewed two (2) clients, they stated they were happy with the care they are receiving at the facility. LPA reviewed 3 staff and administrators file and found they contained the required documents, certification, and training. LPA interviewed two (2) staff, and all were able to answer questions regarding policy, procedures, and personal rights.

Medications LPA reviewed the medications and Medication Administration Record (MAR) for four (4) clients. LPA observed Centrally Stored Medications in their original packaging. All medications are secured in a locked cabinet in the kitchen and are inaccessible to clients. LPA observed four (4) out of four (4) MARs and medication are consistent with properly documented records.

Infection Control LPA observe the infection control procedures. LPA observed a sanitizing station and visitor log at the entrance of the facility. All required infection control signs were observed posted throughout the facility. The facility has a 30-day supply of PPEs.

During today’s visit no deficiencies were observed or cited.

An exit interview was conducted with Designate Noel Figueroa, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3