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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601843
Report Date: 04/08/2024
Date Signed: 04/08/2024 04:19:04 PM

Document Has Been Signed on 04/08/2024 04:19 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:219TH FACILITYFACILITY NUMBER:
198601843
ADMINISTRATOR/
DIRECTOR:		JENNIFER CRIDDLEFACILITY TYPE:
735
ADDRESS:1563 W 219TH STTELEPHONE:
(310) 533-9870
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 3CENSUS: 3DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:41 PM
MET WITH:Tanisha McCallTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 04/08/2024 at 1:41 PM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator Tanisha McCall. LPA explained the purpose of the visit and were accompanied by Administrator inside and outside the facility during this inspection.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client bedrooms, two (2) common bathrooms, living area, dining area, kitchen, family room, garage and outside covered patio.

The facility is licensed to operate for one (1) non-ambulatory and two (2) ambulatory adults ages 18-59.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

3 out of 3 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Cloyd tested hot water temperature and it measured 109 degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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 2
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: 219TH FACILITY
FACILITY NUMBER: 198601843
VISIT DATE: 04/08/2024
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LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 03/06/24. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

Five (5) staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions. Two staff members were interviewed.

Three (3) client records were reviewed and, 3 out of 3 client records had Admission Agreements, Medical Assessments, and/or Needs & Services Plans. Two client medications were reviewed. LPA Cloyd reviewed P&I money, 3 out of 3 residents P&I were not commingled with facility funds or petty cash.

No deficiencies cited.

An exit interview was conducted and a copy of this report was discussed and left with the Administrator Tanisha McCall.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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