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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601965
Report Date: 07/08/2024
Date Signed: 07/08/2024 03:56:30 PM

Document Has Been Signed on 07/08/2024 03:56 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:LURAY HOMEFACILITY NUMBER:
198601965
ADMINISTRATOR/
DIRECTOR:		SHIRENA L MUHAMMADFACILITY TYPE:
735
ADDRESS:930 E. LURAY STREETTELEPHONE:
(562) 612-3752
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 3CENSUS: 1DATE:
07/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:46 PM
MET WITH:Maria Varcelo, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
04:32 PM
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On 07/08/2024 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, case management annual continuation visit using the CARE Inspection Tool. LPA was met by Maria Varcelo, Direct Support Professional (DSP) and the purpose of today’s visit was explained.

The annual visit consisted of the following: Tour of the facility, LPA's water temperature measurements and LPA's observation which included two (2) deficiencies being cited.

Today's visit consisted of the following:
LPA reviewed two (2) resident's service files and both (2) Medication Admission Records. Both files LPA reviewed were complete. LPA reviewed two (2) most recent staff (S1-S2) who have conducted recent support at the facility. According to California code of regulation, state licensing standards, both (2) files were complete and the staff files displayed adequate resource(s) to provide provision and care to the two (2) clients in care.

There have been no additional deficiencies cited during today's visit.

An exit interview was held with Maria Varcelo, DSP, and a copy of this report has been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2024
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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