198601542-12-7-2023-11-AS-WGIS-CYASEH-20231207124847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601542
Report Date: 12/07/2023
Date Signed: 12/07/2023 12:49:02 PM

Document Has Been Signed on 12/07/2023 12:49 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:	WILKIE HOME		FACILITY NUMBER:	198601542
ADMINISTRATOR:	MARGARITA NUNEZ RENTERIA		FACILITY TYPE:	735
ADDRESS:	17234 WILKIE AVE		TELEPHONE:	(310) 538-8599
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY: 3		CENSUS: 3	DATE:	12/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ghani Dickerson		TIME COMPLETED:	01:00 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 12/07/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the full CAREs tool. LPA met with Direct Support Professional, Ghani Dickerson and Nanda Aung, and the purpose of today's visit was explained. The facility is licensed for three (3) developmentally disabled adults. During time of visit there were two (2) clients present. Physical Plant/Structure The facility is a single-story home in a residential neighborhood. The facility consists of three (3) bedrooms, two (2) bathrooms, kitchen, dining room, laundry room, living room, sitting room, outdoor activity area, and detached garage. The back yard has a patio with a shaded swing. All walkways outside were observed clean, clear, and free of debris, hazards, and obstructions. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected all bedrooms; they were observed clean and in good repair. LPA observed bedrooms to have the required furniture including a bed, dresser, nightstand, chair, and ample storage space for client’s personal belongings. Beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. All linens were observed in good repair. LPA observed an adequate supply of linens in good repair. Bedrooms were observed with adequate lighting. Bathrooms LPA inspected both bathrooms and found them to be within Tittle 22 Regulations. Bathroom were observed clean, operable, and in good repair. Showers were observed free of mildew and/or mold. Showers have secured safety handrails, nonskid mats, and shower chairs. LPA observed an ample supply of personal hygiene products stored in the laundry room. The water temperature measured 114.7-degrees and 114.0-degrees Fahrenheit. Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed an ample supply of cookware, dining ware, and cutleries in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly labeled and stored. All appliances were observed operable. The water temperature measured 117.1-degrees Fahrenheit. LPA observed all sharps secured in a locked cabinet in the laundry room and are inaccessible to clients. LPA observed cleaning supplies secured in a locked cabinet in the laundry room and are inaccessible to clients.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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 2

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: WILKIE HOME	FACILITY NUMBER: 198601542
	VISIT DATE: 12/07/2023

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

Common Rooms LPA inspected all common rooms. The living room has a couch and three chairs to accommodate all clients. The sitting room has two (2) couches and a chair to accommodate clients. LPA observed a fireplace screened and not accessible to clients. The dining room has a large rectangular table with chairs to accommodate all clients. LPA observed games, puzzles, and activities stored in the laundry room. The facility was maintained at a comfortable temperature. LPA observed all walkways to be clean, clear, and free of hazards and obstructions. All rooms have ample lighting.
Medications LPA observed centrally stored medications secured in a locked cabinet in the kitchen and are inaccessible to clients. All medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Records (MARs) for two (2) clients. The client’s MARs and medication are consistent with properly documented records.
Files/Interview LPA reviewed two (2) client files and observed the files contained the required documents. LPA reviewed the Administrator’s and two (2) staff files and observed they contained the required documents, certification, and training. LPA interviewed the staff, and all were able to answer questions regarding client care, procedures, policies, and client personal rights. LPA reviewed the staff training logs and observed staff have the required training hours and attend training's on a monthly basis.
Safety LPA observed all required signs and documents posted throughout the facility. Smoke detectors and Carbon Monoxide detectors are operable. LPA observed two (2) fully charged fire extinguishers, last serviced on 01/19/23. The last facility inspection from the Torrance Fire Department was on 01/19/23. LPA inspected the First Aid Kit and found it contained the required items and a manual. The last emergency drill was conducted on 09/01/23. The facility has a working landline telephone. There are no firearms or ammunition stored at the facility.
Infection Control Upon entry LPA observed a sign-in for visitors and a hand sanitizing station at the front door. LPAs temperature was taken upon entry. LPA reviewed staff and visitor temperature log. LPA observed mandated infection control signs posted throughout the facility. LPA observed a 90-day supply of Personal Protective Equipment (PPE).

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Direct Support Professional, Nanda Aung, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2