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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601785
Report Date: 07/01/2024
Date Signed: 07/01/2024 03:57:23 PM

Document Has Been Signed on 07/01/2024 03:57 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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:
07/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:01 PM
MET WITH:sandra moraga/administratorTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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On 07/01/2024, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Troy Watson conducted an unannounced Case Management - Deficiencies visit. The purpose of this visit is to document deficiencies observed during the investigation of a complaint with Complaint Control Number 11-AS-20240628150810.

During the investigation LPM and LPA observed that client bedroom (Bedroom#1) was being used as a passageway to the Administrator's office. The administrator stated that Bedroom#1 is being used by staff to access the Office within the last 2 tears now. Title 22, Division 6, Chapter 6 are being cited on the attached LIC809D.

An exit interview was conducted and plans of corrections were developed. A copy of this report and appeals rights were provided to Sandra Moraga.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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Document Has Been Signed on 07/01/2024 03:57 PM - It Cannot Be Edited


Created By: Troy Watson On 07/01/2024 at 03:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SPECIALIZED RESIDENTIAL 118TH STREET
FACILITY NUMBER: 198601785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2024
Section Cited
CCR
85087(a)(4)

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85087 Buildings and Grounds
(a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements: (4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet. This requirement was not met as evidenced by:
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The Licensee will create a plan to ensure that bedroom#1 is not used as a passageway to the administrator's office, proof of correction will be emailed to troy.watson@dss.ca.gov.
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Based on interviews and observation Bedroom#1 was being used as a passageway to the Administrator's office. which poses a potential risk to the health, safety and personal rights of clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Troy Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024


LIC809 (FAS) - (06/04)
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