198601542-12-10-2024-11-AS-WGIS-DBTUDM-20241210142945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601542
Report Date: 12/10/2024
Date Signed: 12/10/2024 02:29:55 PM

Document Has Been Signed on 12/10/2024 02:29 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/ DIRECTOR:	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:	12/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Yanette Aguilar		TIME VISIT/ INSPECTION COMPLETED:	02:30 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 12/10/24, the department conducted an unannounced annual visit using the full CAREs tool. The department met with Administrator, Yanette Aguilar and Program Supervisor, Spencer Croasdale, the purpose of today's visit was explained. The facility is licensed for three (3) non-ambulatory 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, office area, outdoor activity area, and detached garage. The back yard has a shaded patio with a swing, table, and chairs. All walkways outside were observed clean, clear, and free of debris, hazards, and obstructions. All safety handrails were observed secure and in good repair. The department did not observe any bodies of water on the premises. Bedrooms The department inspected all bedrooms; they were observed clean and in good repair. The department 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. (1) Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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 4

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: 12/10/2024

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

All bedrooms were observed with adequate lighting.
Bathrooms The department inspected both bathrooms and found them to be within Title 22 Regulations. Bathrooms 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. The department observed an ample supply of personal hygiene products stored in the laundry room. The water temperature measured 113.1-degrees and 116.6-degrees Fahrenheit.
Kitchen The department inspected the kitchen and found it to be clean and sanitary. The department observed an ample supply of cookware, dishware, and cutleries in good repair. The department observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly labeled, dated, and stored. All appliances were observed operable. The water temperature measured 111.2-degrees Fahrenheit. The department observed all sharps secured in a locked cabinet in the laundry room and are inaccessible to clients. The department observed cleaning supplies secured in a locked cabinet in the laundry room and are inaccessible to clients.
Common Area The department inspected all common areas and observed the facility to be appropriately furnished. The living room has a couch and three chairs to accommodate all clients. The office area has a couch to accommodate clients. The department observed a fireplace screened and is not accessible to clients. The dining room has a large rectangular table with chairs to

(2) Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: 12/10/2024

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

accommodate all clients. The department 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 were observed to have ample lighting.
Medications The department 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. The department 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 The department observed files secured in a locked closet in the dining room and are inaccessible to clients. The department reviewed three (3) client files and observed the files contained the required documents. The department reviewed two (2) client Personal and Incidental (P&I) funds. The department received and reviewed the Surety Bond. The department reviewed the Administrator’s and three (3) staff files and observed they contained the required documents, certification, and training. The Administrator’s Certificate is valid till 10/03/26. The department reviewed the staff training logs and observed staff have the required training hours and attend trainings on a monthly basis. During file review, the department received confirmation that licensing annual fees are current.
Safety The department observed all required signs and documents posted throughout the facility. Smoke detectors and Carbon Monoxide detectors are operable. The department observed two (2) fully charged fire extinguishers, last

(3) Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 12/10/2024

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

serviced on 10/01/24. The last facility inspection from the Torrance Fire Department was on 02/02/24. LPA inspected the First Aid Kit and found it contained the required items and a manual. The last emergency drill was conducted on 10/02/24. The facility has a working landline telephone. There are no firearms or ammunition stored at the facility.
Infection Control Upon entry the department observed a sign-in for visitors and a hand sanitizing station at the front door. The department observed infection control signs posted throughout the facility. The department observed a 60-day supply of Personal Protective Equipment (PPE).

During today's visit, the department did not observe or cite any deficiencies.

Advisory Notes- Technical Violation (LIC9102).

An exit interview was conducted with Administrator, Yanette Aguilar and Program Supervisor, Spencer Croasdale, and a copy of this report was provided.

(4)

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4