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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600956
Report Date: 05/23/2025
Date Signed: 05/23/2025 04:34:20 PM

Document Has Been Signed on 05/23/2025 04:34 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/
DIRECTOR:		BETH KAZUYE FIGUEROAFACILITY TYPE:
735
ADDRESS:2505 WEST 180TH STREETTELEPHONE:
(310) 538-9978
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 4CENSUS: 4DATE:
05/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Teresita MirandaTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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On 05/23/25, 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 Licensee, Patrick Figueroa. The facility is licensed to serve four (4) developmentally disabled clients ages 18-59.
Physical Plant/Structure The facility is a single-story house in a residential neighborhood. The facility consists of (4) client rooms, (1) staff room, (2) bathrooms, office area, living room, kitchen, dining area, 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 them to be clean and in good repair. All 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 in good repair. All bedrooms were observed with ample lighting.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2025
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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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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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: 05/23/2025
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Bathrooms LPA inspected the bathrooms and found them to be operational and in good repair. The showers were observed free of mildew and/or mold. LPA observed showers have non-slip mats and a shower chair. LPA observed an ample supplies of hygiene products and towels for client use. The water temperature measured 117.8-degrees and 118.3-degrees Fahrenheit.
Kitchen LPA observed the kitchen to be clean and sanitary. All appliances were tested and found to be operational. 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 properly stored. A sample menu was posted on the refrigerator. All sharps are secured in a locked cabinet in the kitchen and are inaccessible to clients. All cleaning supplies are secured in a locked cabinet in the laundry room and are inaccessible to clients. The water temperature measured 118.7-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 in the facility to be clean, clear, and free of obstructions and hazards. All rooms were observed with ample lighting. The facility was appropriately furnished during the time of visit. The facility was maintained at a comfortable temperature.
Safety Smoke and Carbon Monoxide Detectors were observed operational. LPA observed two fully charged fire extinguishers last serviced on 04/18/2025. The last emergency drill was conducted on 05/11/25. The last Fire Prevention Inspection was last conducted on 05/13/2024. LPA reviewed the Emergency and Disaster
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PRISCILLA'S HOME
FACILITY NUMBER: 198600956
VISIT DATE: 05/23/2025
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Plan (LIC610D) and observed it was last updated on 01/31/2025. The First Aid Kit was inspected and found to contain all required items and a current manual. The facility has a working landline telephone. LPA observed all required documents posted throughout the facility. There are no firearms stored on the premises.
Files LPA reviewed all client files and found they contained the required documents. LPA reviewed Client's Personal and Incidental (P&I), and receipts. LPA observed they are consistent with ledgers. LPA reviewed a copy of the Surety Bond with State Farm insurance that is valid till 03/05/2026. LPA reviewed 3 staff and administrators file and found they contained the required documents, certification, and training. The Administrator Certificate is valid till 07/10/2026. LPA observed Licensing Fees are current.
Medications LPA observed Centrally Stored Medications are secured in a locked cabinet in the kitchen and are inaccessible to clients. LPA observed medication are in the original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for four (4) clients. LPA observed four (4) out of four (4) client’s 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 Personal Protective Equipment (PPEs).

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


An exit interview was conducted with Licensee Patrick Figuero, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC809 (FAS) - (06/04)
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