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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601542
Report Date: 12/22/2021
Date Signed: 12/22/2021 05:54:56 PM

Document Has Been Signed on 12/22/2021 05:54 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WILKIE HOMEFACILITY NUMBER:
198601542
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:17234 WILKIE AVETELEPHONE:
(310) 538-8599
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 3CENSUS: 2DATE:
12/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregivers - Ghani Dickerson and Cecelia CallejasTIME COMPLETED:
12:30 PM
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On 12/22/2021, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Caregivers Ghani Dickerson and Cecelia Callejas and explained the purpose of today’s visit. The facility is licensed to serve three (3) non-ambulatory developmentally disabled clients of between the ages of 18 through 59.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client rooms, two (2) bathrooms, two (2) living areas, one (1) dining area, laundry room, kitchen, computer workspace and outside patio area with a table and an umbrella for shade. The garage is detached and used mostly for storage.

LPA and Caregiver Ghani Dickerson toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 113.1 F and 119.3 F in the bathrooms and kitchen sink. A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are two (2) fire extinguishers fully charge, one (1) near the kitchen one (1) in near bedroom #3, smoke detectors and carbon monoxide were operable. A reviewed of Medication Records Administration (MAR) and observed to be maintained in order and accurate.
Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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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Document Has Been Signed on 12/22/2021 05:54 PM - It Cannot Be Edited


Created By: Don Senaha On 12/22/2021 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WILKIE HOME
FACILITY NUMBER: 198601542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a broken drawer to the left side of the stove as you are facing the stove which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2022
Plan of Correction
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Program Manager will fix the broken drawer and send a picture to the LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WILKIE HOME
FACILITY NUMBER: 198601542
VISIT DATE: 12/22/2021
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

There was one deficiency cited during this inspection visit. See LIC809-D page.

An exit interview was conducted and a copy of this report was provided to Area Director Jeri Miles.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC809 (FAS) - (06/04)
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