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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601682
Report Date: 08/09/2024
Date Signed: 08/09/2024 11:38:58 AM

Document Has Been Signed on 08/09/2024 11:38 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ARIEL VISION ARFFACILITY NUMBER:
198601682
ADMINISTRATOR/
DIRECTOR:		OROSZ, TAMIFACILITY TYPE:
735
ADDRESS:2611 W. 181ST STREETTELEPHONE:
(310) 327-5949
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 4CENSUS: 4DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Martha AmparoTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 08/09/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Direct Support Professional, Martha Amparo, and the purpose of today’s visit was explained. The facility is licensed to operate for four (4) ambulatory clients ages 18 through 59. Currently residing in the facility are four (4) clients placed by the Harbor Regional Center. During the time of visit, two (2) clients were present.
Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, two (2) bathrooms, living/office area, kitchen, dining room, attached garage and outside shaded patio area. The backyard has a table with umbrella and chairs. LPA observed all walkways around the facility to be clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all client rooms and observed the walls and floors to be in good repair. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. LPA observed all client rooms had the required furniture including a bed, dresser, nightstand, storage (1) Continued On LIC809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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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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: ARIEL VISION ARF
FACILITY NUMBER: 198601682
VISIT DATE: 08/09/2024
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space for personal belonging, and ample lighting. LPA observed all beds had the required linens including a mattress cover, fitted sheet, blanket, comforter, and pillows. LPA observed an ample supply of bed linens, and comforters in good repair stored in the cabinet in the hallway.
Bathrooms LPA inspected the facility bathrooms and found them to be within Title 22 regulations. All bathrooms were observed clean and operational. LPA observed storage area for personal hygiene products for each individual client in the cabinet in the hallway. LPA observed an ample supply of towels and personal hygiene products available for clients. All showers had a nonskid mat. The water temperature measured 109.3-degrees and 107.4-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 108.4-degrees Fahrenheit. 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 under the kitchen sink and are inaccessible to clients.
Common Rooms LPA observed the facility to be appropriately furnished during the time of visit. The facility has a living room with couches to accommodate all clients. LPA observed an ample supply of games, activities, and puzzles available. LPA observed a fireplace screened and inaccessible to clients. The dining room table is
(2) Continued on LIC809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
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: ARIEL VISION ARF
FACILITY NUMBER: 198601682
VISIT DATE: 08/09/2024
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large enough to accommodate clients for meals. LPA observed all walkways and hallways to be clean, clear, and free of hazards and obstructions. All rooms were observed with ample lighting. The facility was kept at a comfortable temperature.
Safety LPA observed two (2) fully charged fire extinguisher, one located in the dining room and the other in the kitchen, last serviced on 01/15/24. All smoke and carbon monoxide detectors are operable. The last emergency drill was conducted on 08/02/24. The last Fire Prevention Inspection conducted by the Torrance Fire Department was conducted on 01/15/24. LPA inspected the First Aid Kit and observed it had the required items and current manual. The facility sketch is posted at the entrance of the facility. The facility’s Emergency and Disaster Plan was observed posted. LPA observed all required documents posted in the facility. The facility has a working landline telephone. There are no firearms are ammunition stored at the facility.
Medication LPA observed all 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 Record (MAR)for the three (3) clients. Three (3) out of three (3) client’s MARs and medication are consistent with properly documented records.
Infection Control Upon entry, LPA observed a sanitizing station and visitor sign-in log. LPA observed on the table there is hand sanitizer, sanitizing wipes, and masks available. LPA observed all required Infection Control signs posted in the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE) stored in the garage.
(3) Continued on LIC809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
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: ARIEL VISION ARF
FACILITY NUMBER: 198601682
VISIT DATE: 08/09/2024
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File Review LPA reviewed the files for the four (4) clients and observed they had the required documents. LPA reviewed the administrator and two (2) staff files and found they contained the required documents, certification, and training. The administrator’s Administrator Certificate is valid till 01/19/26. LPA reviewed the clients P & I and receipts from purchases. LPA spoke with the Administrator and provided a reminder that licensing fees are due on 08/18/24 and LPA provided staff with the PIN to pay online.

LPA did not observe or cite any deficiencies.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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