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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601785
Report Date: 04/12/2023
Date Signed: 04/12/2023 10:54:32 AM

Document Has Been Signed on 04/12/2023 10:54 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:SPECIALIZED RESIDENTIAL 118TH STREETFACILITY NUMBER:
198601785
ADMINISTRATOR:SANDRA MORAGAFACILITY TYPE:
735
ADDRESS:5424 W 118TH STTELEPHONE:
(909) 287-3557
CITY:INGLEWOODSTATE: CAZIP CODE:
90304
CAPACITY: 3CENSUS: DATE:
04/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Sandra MoragaTIME COMPLETED:
11:00 AM
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On 4/12/2023, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by staff and explained the purpose of today’s visit is the annual inspection concentrating on Infection control measures and was allowed entry into the facility. The facility is an Adult Residential Facility ages 18 to 59, licensed for 2 non-ambulatory and 1 ambulatory client. There are currently three (3) clients in placement.

The facility is a single-story home located in a residential neighborhood. The facility consists of three (3) client bedrooms, two (2) bathrooms, living room, office area, dining room, two (2) backyard patio areas, laundry area and attached garage. Water delivered at 116.8 F.

LPA and staff toured the physical plant. There were no bodies of water or obstructions on the premises. LPA observed no chairs to table on patio. Administrator Sandra provided proof of order of patio chairs to be delivered tomorrow as they are remodeling before the summer. 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.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is a 3-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. Two fully charged fire extinguishers was found hallway off of kitchen and second is in living room.

Continued on 809C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SPECIALIZED RESIDENTIAL 118TH STREET
FACILITY NUMBER: 198601785
VISIT DATE: 04/12/2023
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During the visit, LPA observed the facility infection control practices. Administrator conducts monthly fire drills. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, a 30-day supply of Personal Protective Equipment (PPE) is available and sign in and out logs for visitors and staff are present in the facility.

No deficiencies were cited during visit.

An exit interview was conducted, and a copy of this report was provided to Sandra Moraga.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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