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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601785
Report Date: 04/04/2024
Date Signed: 04/05/2024 03:45:48 PM

Document Has Been Signed on 04/05/2024 03:45 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:SPECIALIZED RESIDENTIAL 118TH STREETFACILITY NUMBER:
198601785
ADMINISTRATOR/
DIRECTOR:		SANDRA MORAGAFACILITY TYPE:
735
ADDRESS:5424 W 118TH STTELEPHONE:
(909) 287-3557
CITY:INGLEWOODSTATE: CAZIP CODE:
90304
CAPACITY: 3CENSUS: 3DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Sandra MoragaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and LPA temperature was checked. LPA Bunker met Administrator Sandra Moraga and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report and infection control plan. There are currently three (3), Westside Regional Center Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

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

Due to time constraints, LPA Bunker will come back at a later date to complete the visit. There were no deficiencies cited.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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