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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601312
Report Date: 10/17/2023
Date Signed: 10/18/2023 08:59:29 AM

Document Has Been Signed on 10/18/2023 08:59 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:WILLIAMS ADULT FACILITYFACILITY NUMBER:
198601312
ADMINISTRATOR:LAURIE WILLIAMSFACILITY TYPE:
735
ADDRESS:731 W. CHERRY STREETTELEPHONE:
(310) 438-0051
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 4CENSUS: 4DATE:
10/17/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Laurie Williams TIME COMPLETED:
02:47 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 10/17/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management visit at this facility. LPA met with administrator Laurie Williams and explained the purpose of the visit was to gather information for a complaint in association with facility Willing Workers Inc #191800884 complaint # 11-AS-20231016153724.

LPA interviewed the administrator during this visit between 01:30 pm 1:59 pm. LPA collected the following information associated with client #1 (C1):
  • Photographs of (5) medications
  • Face Sheet
  • Medication Administration Record (dated: 10/01/23 - 10/31/23)
  • Physicians Report LIC 602 (dated: 04/28/23)
  • Client Development Evaluation Report (dated: 02/04/22)
  • Individual Psychological Assessment Report (dated: 07/18/10)
  • Los Angeles Police Report (dated: 10/16/23)
  • Semi Annual IPP (dated: 01/01/23 - 06/30/23)
  • Medical and Physiological Reports

An exit interview conducted with Laurie Williams and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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 1